Enhancing Value in Medicaidfor Children in Foster Care

Sheila A. PiresHuman Service Collaborative

Three Branch Institute on Child Social and EmotionalWell-Being: Meeting for State Teams

July 25, 2013Philadelphia, PA

Lessons from States

Design elements and contractual specs need to reflect state child welfare, Medicaid

and behavioral health system policy and goals –

Collaborative planning, design, implementation needed; also, state agencies need to approach implementation

in partnership with managed care entities

Eligibility and Enrollment (State policies that affect access)

Presumptive eligibility (MA, MI) or fast track enrollment

Continued eligibility for youth transitioning out offoster care (2014 ACA requirement – to age 26)

• Implications for coverage of home and community services• Addiction and mental health treatment accounted for

42% of hospital claims for 19-25 year olds enrolled intheir parents’ health plans in 2011 through ACA (EmployeeBenefit Research Institute, April 2013)

• Greater prevalence in transition-age foster care population

Transition coverage upon leaving foster care (any age) • AZ: 60 days of coverage post foster care exit

Youth involved in both foster care and juvenile justice –Suspend rather than terminate Medicaid eligibility if youth is injuvenile justice facility

Trauma-Informed Screening and Early Intervention(3/27/13 CMCS and SAMHSA Informational Bulletin and 7/11/13 SMD Letter)

Incorporate state child welfare requirements for physical, behavioral and dental health screens within specified timeframes

AZ: Urgent response requiring behavioral healthscreen within 72 hrs of entering care and “fast track”linkage to servicesMA: Medical screening required within 7 days and comprehensiveexam within 30 days, including behavioral health

Mandate use of standardized screening tools and inclusionof behavioral and developmental (not only physical health) screens

Quality payments for providers meeting trauma-informed standards

May require enhanced rate (MA)

Service Coverage

Cover a broad array of behavioral health home andcommunity-based services (May 7, 2013 CMCS and SAMHSA

Informational Bulletin)AZ: In-home services; respite; life skills training; family and

youth peer support; therapeutic foster care; case management;supported housing; supported employment; mobile crisis

intervention; crisis stabilization; transportation; Wraparoundprocess

MA: In-home services; family peer support; mobile response; therapeutic mentoring; behavior management therapy and

behavior therapy monitoring; intensive care coordination usinga Wraparound approach

NJ: Mobile response and stabilization; therapeutic group home care;treatment homes/therapeutic foster care; intensive care management;

Wraparound process; behavioral assistance; intensive in-home/communityservices; transportation; youth support and development

Service Coverage

Cover evidence-based practices, e.g. Trauma-FocusedCognitive Behavioral Therapy , Multisystemic Therapy,

Functional Family Therapy, Multidimensional TreatmentFoster Care (growing number of states)

A word about a “special benefit” for foster care population througha foster care carve out –

TANF (and SSI children) need the same service array as foster care pop (while prevalence rate for behavioral health is higher for children

in foster care than TANF population, there are many more TANF children)Children don’t stay in foster care forever (median LOS in 2011 was

13.2 mos) but may remain Medicaid-eligible and in need of servicesCan lead to unintended consequence of parents having to relinquish

custody to access care (especially an issue for children with serious behavioral health challenges)

Provider Network

Mandate inclusion of providers knowledgeable aboutthe child welfare population

• AZ: sexual abuse, trauma• MA: state required same network of providers across all MCOs for

behavioral health home and community-based services (Rosie D);requirements for expertise in trauma-informed care

• TN: Best Practices NetworkAllow out-of-network specialists if needed (MA, MI)

Develop protocols and practice guidelines relatedto children in foster care and interface with child welfaresystem

• AZ: how to work with the child welfare agency and the courts;clinical needs of the child welfare population

Orientation and Training

Incorporate orientation/training for MCOs on fostercare population, child welfare system, role of court

Incorporate training for Medicaid providers on effectivepractices

• Wraparound approach (MA, MI, NJ, LA, MD)• Trauma-Focused CBT and Parent Management Training-Oregon

Model (MI)• Trauma-informed care (AZ, MA)

• Screening tools (MA)

Customized Care CoordinationIncorporate intensive care coordination using Wraparound

approach for children with serious behavioral health challenges(growing number of states – MA, LA, NJ; PRTF Waiver Demo

states; CHIPRA Care Management Entity Quality Collaborativestates – better outcomes, lower per capita costs. May 7, 2013

CMCS Informational Bulletin• Intensive care coordination rates for this population range from

$780 pmpm to $1300 pmpm (CHCS Matrix)• In high fidelity intensive care coordination/Wraparound approaches,

all-inclusive cost of care (e.g., admin, care coord, placements, clinicaltreatment, informal supports) averages $4200 pmpm – compare to

$8,000 pmpm in PRTFs, higher in psych hospital

Require that every child has a designated primary care providerand coordination between physical and behavioral health careprovidersRequire coordination with child welfare systemRequire coordination with Part C, CSHCN

Psychotropic Medications (8/24/12 and 11/23/2011 CMCS Informational Bulletin and SMD)

Require tracking and monitoring of outlier use, e.g.too young, too many, too much, (growing number

of states) – interface with Drug Utilization Review Board

Require consultation to prescribers, including primarycare providers (MA, VT)

Orient MCOs to state’s informed consent and assentpolicies in child welfare

Provide coverage and training for treatment alternatives(aggression, sleep disorders)

Financing Incentives

Risk-adjusted rates for the foster care population• AZ BH carve out: capitation rate is 29% higher than for children

in generalIncentive payments to providers (MI BH carve out)

Adequate intensive care coordination rates using fidelityWraparound (e.g. specified care coordination rate or “pass-through” case rate for high utilizers)

Enhanced rate for comprehensive physical, behavioraland development screens (MA)

Explore potential for Medicaid match from child welfare –most children are Medicaid eligible; many services paid for bychild welfare are Medicaid-allowable (NJ, AZ, MI)

Values-Based, Goal-Oriented Utilization Management Criteria

Access: require no prior authorization for basic behavioralhealth outpatient services (MA)

Coordinated Care: require that plans of care developedthrough Wraparound process determine medical necessity (with

outlier management) (AZ, MA, NJ, LA)

Require no “fail first” criteria to access services or medications

Prior auth for certain psychotropic meds, e.g. antipsychoticsfor young children (MD)

Data and Performance RequirementsRequire specific tracking and reporting of:

• Foster care population penetration rate and utilization (services and medications)

• Performance expectations (not only HEDIS)AZ: PH-access to primary care, adolescent well care visits, annual dental

visits, immunization measures; BH-emotional regulation, avoidingdelinquency, stability of living situation, substance abstinence, children in

psych hospitals awaiting placementsMI: BH-reduced use of residential treatment, maintenance in the

community, improved functioning using CAFASNJ: PH-timeliness of assessments and comprehensive exams; exams

in compliance with EPSDT guidelines; semi-annual dental checks;immunization measures; BH-access to BH services following EPSDT

assessment; clinical and functional outcomes using CANS• Require periodic focus groups/surveys with child welfare

workers, youth and families/caregivers • Require electronic health record/health passport and interface

with child welfare IT system (SACWIS)

Administrative Requirements

Designated liaison within MCO to child welfare systemPeriodic meetings between MCOs, Medicaid and child welfare

system for trouble-shooting, quality improvementInclusion of families and youth with lived experience in

quality review process, as system navigators, as advisory bodymembers

“Warm line” for child welfare workers and caregivers

It is also very helpful to have child health units or designatedstaff in child welfare to interface with MCOs; Medicaid

administrative case management and Title IV-E can both be usedto help finance this capacity (NJ, UT)

Section 2703, Patient Protection and Affordable Care Act

• Authorizes health home services for Medicaid enrollees with chronic conditions

• Authorizes 90% Federal match for 1st eight quarters

• Designed to facilitate access to and coordination of physical and behavioral health care and long term community-based services and supports

• Goal of improving the quality and cost of care and enrollee’s experience with care

Provisions

Health Home Eligibility

• At least two chronic conditions, or• One chronic condition and at risk for another, or• One serious and persistent mental health condition

Can target health home services to those with particular chronic conditions or with higher severity of chronic condition, but cannot target by age

Medicaid comparability is waived – can offer health home services in a different amount, duration and scope than offered to individuals not in health home and can target by geographic area

Health Homes vs Medical Homes

Medical Homes

All children

Coordination of medical care

Physician-led primary care practices

Health Homes

Children with chronichealth conditions, childrenwith serious behavioral health conditions

Coordination of physical,behavioral, and social supports

Specialty provider organizations,including behavioral health specialtyorganizations (e.g., not only medical)

Analysis of Medical Home Services for Children with Behavioral Health Conditions*

“All behavioral health conditions except ADHD associated with difficulties accessingspecialty care through medical home”

“The data suggest that the reason why services received by children and youth with behavioral health conditions are not consistent with the medical home model

has more to do with difficulty in accessing specialty care than with accessingquality primary care”.

Sheldrick, RC & Perrin, EC. “Medical home services for children with behavioral health conditions”. Journal of Developmental Pediatrics, 2010 Feb-Mar 31 (2) 92-9

Children and Youth with Serious Behavioral Health Conditions Are a Distinct Population from Adults with Serious and Persistent Mental Illness

Children with SED do not have the same high rates of co-morbidphysical health conditions as adults with SPMI

Children, for the most part, have different mental health diagnoses from adults with SPMI (ADHD, Conduct Disorders, Anxiety; not so much Schizophrenia, Psychosis, Bipolar as in adults)

Among children with serious behavioral health challenges, two-thirds are also involved with child welfare and/or juvenile justice systemsand 60% may be in special education – governed by legal mandates

Coordination among children’s systems – child welfare, juvenile justice, schools – and among behavioral health providers consumes most of care manager’s time, not coordination with primary care

To improve cost and quality of care, focus must be on child and family

Pires, S. 2012. Human Service Collaborative

*Customizing Health Home Approaches for Children with Serious Behavioral Health Challenges Using HighQuality Wraparound and Intensive Care Coordination

*State may submit one HH State Plan Amendment that incorporates distinct approaches for adults with SMI and

for children with SED, or

*State may submit two separate HH SPAs – one for adults with SMI and one for children with SED – but clock starts on 90%

Federal match with first one approved

CMS-Funded CHIPRA Quality Collaborative onCare Management Entities (Maryland, Georgia, Wyoming)

What is a Care Management Entity?

An organizational entity – such as a non profit organization* - that serves as the “locus of accountability” for defined populations of youth with complex challenges and their families who are involved in multiple systems

Is accountable for improving the quality, outcomes and cost of care for populations historically experiencing high-costs and/or poor outcomes

*Could also be a high quality wraparound teamembedded in a supportive organization (e.g. Oklahoma)

Pires, S. 2010. Human Service Collaborative

Care Management Entity FunctionsAt the Service Level: Child and family team care planning and oversight using high quality

Wraparound practice model Screening, assessment, clinical oversight Intensive care coordination at low ratios (1:8-10) Care monitoring and review Peer support partners Access to mobile crisis supports

At the Administrative Level (directly or in partnership): Information management – real time data; web-based IT Provider network recruitment and management (including natural

supports) Utilization management Continuous quality improvement; outcomes monitoring Training

Pires, S. 2010. Human Service Collaborative

Core Health Home Services• Comprehensive care management Identifying, screening and assessing children appropriate for HH Youth and family engagement Mobilizing child and family team Development and updating of coordinated plan of care Monitoring of clinical and functional status

• Care coordination and health/mental health promotion Ensure coordinated implementation of plan of care Support youth and family to make and keep appointments and to achieve goals Facilitate linkages for youth and family and among providers and systems Ensure communication across providers, systems and with youth and families

• Comprehensive transitional care from inpatient to othersettings, including appropriate follow-up For children, other out-of-home treatment settings, e.g. residential treatment

• Individual and family support services Family and youth peer support (families/youth with lived experience)

• Linkage to social supports and community resources

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Wraparound Milwaukee (1915 a)

Wraparound Milwaukee. (2010). What are the pooled funds? Milwaukee, WI: Milwaukee Count Mental Health Division, Child and Adolescent Services Branch.

CHILD WELFAREFunds thru Case Rate

(Budget for InstitutionalCare for Children-CHIPS)

JUVENILE JUSTICE(Funds budgeted for

Residential Treatment forYouth w/delinquency)

MEDICAID CAPITATION(1557 per month

per enrollee)

MENTAL HEALTH• Crisis Billing• Block Grant

• HMO Commercial Insurance

Wraparound Milwaukee*Care Management Organization

$47MPer Participant Case Rates fromCW ,JJ and ED range from about$2000 pcpm to $4300 pcpm

Intensive Care Coordination

Child and Family Team

Provider Network210 Providers70 Services

Plan of Care

11.0M 11.5M 16.0M 8.5M

Families United$440,000

SCHOOLSyouth at risk for

alternative placements

Mobile Response & Stabilization co-funded by schools, child welfare, Medicaid & mental health

*All inclusive rate (services, supports, placements, care coordination, family support) of $3700 pcpm; care coordinationportion is about $780 pcpm

UMDNJ Training & TA Institute

Department of Children and FamiliesDivision of Child Behavioral Health Services(now Division of Children’s System of Care)

Dept. of Human ServicesMedicaid Division

BH, CW, MA $$ - Single Payor

Provider Network

Contracted Systems Administrator- PerformCare – ASO for child BH carve out

• 1-800 number• Screening• Utilization management• Outcomes tracking

Any licensed DCF provider

Family peer support,education and advocacyYouth movement

Lead non profit agencies managingchildren with serious challenges, multisystem involvement

New Jersey

*Care Management Entities- CMOs

Family SupportOrganizations

*Care coordination rate of $1034 pcpm

Louisiana (1915 b and 1915 c waivers)

State Purchaser –

Medicaid and BHContracting

Claims processingPayment of providers

Training andCapacity building

Statewide Management

Organization (ASO) - Magellan Registration

Determination of appropriateness Ongoing services auth

Population level tracking/UM/UR/Quality assurance/Outcomes management/monitoring

*Regional Care Management

Entities – non profit specialty providersScreening, intake, initial service auth

child and family teamsintensive care management,

connection to natural supports Indiv level tracking/UM/UR/Quality assurance/

Outcomes management/monitoringShared MIS with SMO

Local Providers andNatural Supports

Family SupportOrgs. – family-run

Provide/build capacity forParticipation in policy making and Quality improvement at all levels,

Participation in child/family teams, Family liaisons,

Family educators, Youth peer mentors

manage provider network

support as needed from ASO

work w ASO to fill provider gaps

Interagency Governance

*Care coordination rate of $1035 pcpm

Massachusetts (1115 Waiver)

MCO MCO MCO MCO PCCM BHO

State Medicaid Agency - Purchaser

*Locally-Based Care Management Agencies (called Community Services Agencies) – Non Profit Specialty

Organizations

• Ensure Child & Family Team Plan of Care• Ensure Intensive Care Coordination• Link to peer supports and natural helpers• Manage utilization , quality and outcomes at service level

Standardized tools for screening and assessment

*Care Coordination Rate: Massachusetts does not use a PMPM rate. However, for comparative purposes , (if assuming a productivity standard of approximately 26 hours a week, and an average caseload of 10), the 15-minute rate for Care Coordination and Family Support &Training may appear to suggest a PMPM of $1,100 - $1,200.

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High Quality Wraparound Team as Health TeamOklahoma

Community Mental Health Center

Health Team for Health Team forAdults with SMI: Children with SED:

Nurse Care Manager Wraparound FacilitatorACT Team Intensive Care Coord.Adult Peer Consumer Family and youth peer

support

Improve quality and cost of care

Coordination with Primary Care in a Wraparound Approach

For children with complex behavioral health challenges enrolled inHealth Home, Care Management Entity or Wraparound Health Team is responsible for:

Ensuring child has an identified primary care provider (PCP)

Tracking of whether child receives EPSDT screens on schedule

Ensuring child has at least an annual well-child visit

Communicating with PCP opportunity to participate in child and family team and ensuring PCP has child’s plan of care and is informed of changes

Ensures PCP has information about child’s psychotropic medication andthat PCP monitors for metabolic issues such as obesity and diabetes

Important to Ensure --

• Health home services do not duplicate those of othermanagement entities – for example, patient-centeredmedical homes, managed care organizations, targeted case management providers

Develop matrices that show distinct functions of each and interface between health home and these other entities

Options to Avoid Duplication with Targeted Case Management• Replace TCM with HH SPA

• Distinguish TCM and HH populations: keep TCM for children at high risk and designate HH for children with most serious, complex behavioral health challenges

• Distinguish TCM and HH functions for same population/ HH asaugmentation of TCM - HH rate does not include aspects of care coordination provided through TCM function

Important to Ensure --

• Sufficiency of rate In Care Management Entity approaches nationally, care coordination rate

ranges from about $780 pmpm to about $1300 pmpm

Other Lessons*New York’s Chronic Illness Demonstration Project: Lessons for MedicaidHealth Homes. December 2012. Center for Health Care Strategies

Establish much closer connections from the outset between theorganizations responsible for case management and provider organizations Address data sharing issues and needs Ensure reimbursement for location and enrollment of high risk, high costenrollees Extensive education required to build good relationships with other organizations,be clear on roles, build consistent communication mechanisms “Given the intensity of the job, it was difficult to hire the right people to docommunity-based case management with clients, and there was considerableturnover…Need workforce training that prepares case managers to provide coordinatedpatient-centered care… and a particular emphasis on training peer support specialists”

Federal Medicaid Guidance7/11/13 State Medicaid Director’s Tri-Agency Letter onTrauma-Informed Treatment http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/SMD-13-07-11.pdf

5/7/13 Informational Bulletin on Coverage of Behavioral Health Services for Children,Youth and Young Adults with Significant Mental Health Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-05-07-2013.pdf

3/27/13 Informational Bulletin on Prevention and Early Identification of MentalHealth and Substance use Conditionshttp://www.medicaid.gov/federal-policy-guidance/downloads/CIB-03-27-2013.pdf

8/24/12 Informational Bulletin on Resources Strengthening the Management of Psychotropic Medications for Vulnerable Populationshttp://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-08-24-12.pdf

11/21/11 State Medicaid Directors Tri-Agency Letter on Appropriate Use ofPsychotropic Medications Among Children in Foster Carehttp://www.medicaid.gov/federal-policy-guidance/downloads/SMD-11-23-11.pdf

Resources

Making Medicaid Work for Children in Child Welfare:Examples from the Fieldhttp://www.chcs.org/usr_doc/Making_Medicaid_Work.pdf

Customizing Health Homes for Children with SeriousBehavioral Health Challengeshttp://www.chcs.org/usr_doc/Customizing_Health_Homes_for_Children_with_Serious_BH_Challenges_-_SPires.pdf

Psychotropic Medications Quality Improvement Collaborative:Improving the Use of Psychotropic Medications Among Children in Foster Carehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1261326

CHIPRA Care Management Entity Quality Collaborativehttp://www.chcs.org/info-url_nocat3961/info-url_nocat_show.htm?doc_id=1250388

For further information, contact:

Sheila A. Piressapires@aol.com