Oregon Conference: Transforming Care 2013

Tara LarsonBehavioral Health and Primary Care Integration

in North CarolinaJanuary 8, 2013

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ObjectivesOutline several efforts to support the behavioral health

needs of the Medicaid population in North Carolina through integration between Community Care of NC and the behavioral health Managed Care Organizations.

Describe the complex medical/residential program.Describe the A+KIDS antipsychotic safety registry in North

Carolina.

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Causes of Health Disparities in Behavioral HealthMedications (though problems evident BEFORE antipsychotics

where available)High rates of smoking, lack of weight management/nutrition,

and physical inactivityLack of access to/utilization of preventive community

healthcare, including health promotion services and resourcesPovertySocial isolationSeparation of health and mental health into separate systems

at the federal, state and local level with lack of coordinated infrastructure, policy, planning, quality improvement strategies, regulation or reimbursement

Parks,J, Radke,A, Mazade,N, and Mauer,B NASMHPD 16th Technical Report : Measurement of Health Status for People with Serious Mental Illness. October 16, 2008. 3

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What is the Behavioral Health Initiative?Increase the use of evidence based treatment guidelines for

behavioral health including depression, substance abuse, and ADHD

Increase the number of co-located providersDecrease the re-hospitalization rate for primary psychiatric

admissionsIncrease access to preventive health care to people with

mh/dd/saIncrease coordination of the care for people with mh/dd/sa

through case consultations, data mining, designation of lead coordination

Decrease out of state placements for people with mh/dd/sa and complex medical needs

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Why the Behavioral Health Initiative?CHCS Center for Health Care Strategies, Inc., Dec 2010

Clarifying Multi-morbidity Patterns to Improve Targeting and Delivery of Clinical Services for Medicaid Populations

The analysis confirms the overwhelming pervasiveness of physical and behavioral health co-morbidity among Medicaid’s highest-cost beneficiaries.

Reinforcing earlier analyses, the findings demonstrate that most beneficiaries with the highest hospitalization rates and costs have not one condition, but many. Based upon Medicaid paid claims, 50% of all ED or inpatient admissions had mh/sa/dd diagnosis.

Mental illness is nearly universal among the highest-cost, most frequently hospitalized beneficiaries, and similarly, the presence of mental illness and/or drug and alcohol disorders is associated with substantially higher per capita costs and hospitalization rates.

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Community Care of NC (CCNC): “How it works”

Primary care medical home available to 1.2 million individuals in all 100 counties.

Provides 4,500 local primary care physicians( 94% of all NC PCPs) with resources to better manage Medicaid population

Links local community providers (health systems, hospitals, health departments and other community providers) to primary care physicians , including mental health providers

Every network provides local care managers (600), pharmacists (50+), psychiatrists (14+) and medical directors (20) to improve local health care delivery

Coordinates behavioral health care through the behavioral health MCO/LMEs

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Eligibility and Enrollment in Health Homes

Eligibility for Community Care of North Carolina enrollment includes all categorically-eligible Medicaid recipients including dually eligible individuals and persons enrolled in 1915b/c mh/dd/sa waivers.

Enrollment in the Health Homes program is opt out through enrollment in CCNC.

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Population Management Components for CCNCOutreach / Education / Enrollment / CommunicationScreening / Assessment / Care PlanRisk Stratification / Identify Target PopulationPatient Centered Medical Home – Evidence-based best

practices and team based careTargeted Disease and Care Management Interventions

and Best PracticesPharmacy Management, Medication ReconciliationBehavioral Health Integration Transitional CareSelf Management of Chronic Conditions

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Community Care Networks

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Each CCNC network has:Clinical Director

A physician who is well known in the community Works with network physicians to build compliance with care

improvement objectivesProvides oversight for quality improvement in practices Serves on the Sate Clinical Directors Committee

Network Director who manages daily operationsCare Managers to help coordinate services for enrollees/practicesPharmD to assist with Med management of high cost patientsPsychiatrist to assist in mental health integration

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Current State-wide Diseaseand Care Management Initiatives

Asthma (1998 – 1st Initiative) Diabetes (began in 2000) Dental Screening and Fluoride Varnish (piloted for the state in 2000) Pharmacy Management

Prescription Advantage List (PAL) - 2003 Nursing Home Poly-pharmacy (piloted for the state 2002 - 2003) Pharmacy Home (2007) E-prescribing (2008) Medication Reconciliation (July 2009)

Emergency Department Utilization Management (began with Pediatrics 2004 / Adults 2006 )Case Management of High Cost-High Risk (2004 in concert with rollout of

initiatives) Congestive Heart Failure (pilot 2005; roll-out 2007)Chronic Care Program – including Aged, Blind and Disabled

Pilot in 9 networks 2005 – 2007 Began statewide implementation 2008 - 2009

Behavioral Health Integration (began fall 2010) Palliative Care (began fall 2010)

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1915 B/C Behavioral Health Waiver1915 B/C Behavioral Health WaiverOperated through 11 “quazi governmental entities”

referred to as Local Management Entities (LMEs)Began in 5 counties in 2005 – will be statewide (100

counties) by June 30, 2013. By February 1, 99 counties will be live.

Fully Capitated, at risk for all mh/dd/sa services including ED visits, inpatient, ICF-MR, outpatient, enhanced mh/dd/sa services. Pharmacy is carved out. Some codes in primary care are “unmanaged” for med management and basic services To encourage one stop service delivery

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Proposed Local Management Entity - Managed Care Organizations (LME-MCOs)and their Member Counties - by July 1, 2013

Anson

Ashe

Avery

Beaufort

Bertie

Bladen

Brunswick

Burke

Cabarrus

Caldwell

Carteret

Catawba Chatham

CherokeeClay

Cleveland

Columbus

Craven

Currituck

Forsyth

Gates

Graham

Granville Halifax

HarnettHenderson

Hertford

Jackson

Jones

LeeLincoln

Macon

Madison

MontgomeryMoore

Nash

Northampton

Onslow

Pamlico

Pender

Pitt

Polk

Robeson

Rockingham

Rowan

Rutherford

StokesSurry

Swain

Union

Vance

Wake

Warren

Watauga Wilkes

Wilson

Yadkin

Yancey

Smoky Mountain Center Jul 2012

Unless otherwise indicated, the LME name is the county name(s).The lead LME name for the proposed LME-MCO is shown first. Dates shown are the planned Waiver start dates.Reflects plans as of February 9, 2012.

Orange

Transylvania

Person

Western Region Central Region Eastern Region

Cumberland

Scotland

Haywood

New Hanover

Durham

Alleghany

Alamance

Iredell

Johnston

DuplinSampson

Wayne Lenoir

Dare

Hyde

Martin TyrrellWashington

Camden

PerquimansPasquotank

Greene

AlexanderMitchell

Gaston

Buncombe

CenterPoint Human Services Jan 2013

Caswell

Chowan

Edgecombe

Western Highlands NetworkJan 2012

Davidson

StanlyMecklenburg

McDowell

Durham/ Wake/ Johnston/ Cumberland

Jan 2013

Davie

Coastal Care System(Southeastern Center/ OCBHS)

Jan 2013

Guilford

Randolph

Richmond

# Sandhills Center/ GuilfordDec 2012

East Carolina Behavioral Health Apr 2012

Eastpointe/ Southeastern Regional/

Beacon Center Jan 2013

Mecklenburg Feb 2013

Franklin

Hoke

Partners Behavioral Health Management (Pathways/ MH Partners/ Crossroads)

Jan 2013

PBH/ Alamance Caswell Oct 2011/ Five County Jan 2012/

OPC Apr 2012

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1915b/c Waiver GoalsImproved Quality of CareIncreased Cost BenefitPredictable Medicaid Costs (2009 $22.57 per person, 2012$ 20.88)Combine the management of State/Medicaid Service Funds at the

Community LevelSupport the purchase and delivery of best practice servicesEnsure that services are managed and delivered within a quality

management frameworkEmpower the LME/MCOs to build partnerships with consumers,

providers and community stakeholders with the goal of creating a more responsive system of community care.

Increased consistency and economies of scale in the management of community services

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What does the MCO/LME do for Medicaid? Enroll & monitor providers (statewide)Call Center—Customer SupportMake sure consumers with greatest need get connected to

providers and have treatment plans (Care Coordination)Authorize “medically necessary” servicesPay for mh/sa/dd servicesProvide education about ALL Medicaid benefits to recipients

& consumers (website, mailings, seminars)Reviews, Medications, Hearings (Due Process)Gap analysis/community developmentCCNC collaboration

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Health Homes & Local Management Entities/Managed Care Organizations

CCNC (Community Care of NC) is NC’s Health Home Model with the LME/MCO to address the behavioral health needs through the 1915 b/c waiver

Much work has been done to interface the data sharing and to clarify the roles/responsibilities of LME/MCOs and CCNC (informatics chart attached)

Four Quadrant Care Management ModelDetermines who takes the lead in care managementQuadrants 1 and 3 – CCNC/Primary Care take leadQuadrant 2 – LME/MCO/Behavioral Health take leadQuadrant 4 – flexible sharing of responsibilities

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Four Quadrant Care Management Model

Quadrant I:

Low MH/DD/SA health

Low physical health complexity/risk

Quadrant II:

High MH/DD/SA health

Low physical health complexity/risk

Quadrant III:

Low MH/DD/SA health

High physical health complexity/risk

Quadrant IV:

High MH/DD/SA health

High physical health complexity/risk

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Health Homes & Local Management Entities/Managed Care Organizations Continued . . .

Shared Care Management of recipientsIdentification, linkage to servicesCoordination of MH/SA/DD & physical health needs

Data exchange into InformaticsLME/MCOs signed data-sharing agreements with the CCNC

Informatics CenterCollaboration on integrated care practicesMonthly-quarterly partnership meetings

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Integrated Care Toolkit In August 2011 an MH/DD/SA Integrated Care Toolkit was published to

assist MH/DD/SA providers in collaborating with CCNC and primary care

Among other items, the toolkit includes:A flowchart to determine if an individual has a CCNC health home or

primary care providerA detailed description of the Four Quadrant Care Management Model

Responsibilities

More information on the toolkit can be found in the August 2011 Medicaid Bulletin – http://www.ncdhhs.gov/dma/bulletin/0811bulletin.html#car

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Managing Complex CasesMost recent initiative to integrate medical and behavioral healthcare

NC has historically had to place children out of state who have complex medical and mh issues (such as brittle diabetic and bi-polar disorder)

Team formed with major regional hospital and medical school, specialty physicians, CCNC network, LME/MCO, private providers offering behavioral health residential care (in-home, therapeutic family living and PRTF)

Team follows childSingle payment made for cost of total care (hospital, outpatient) –

bundled paymentLead entity will pay all components providing care Incentive payments will be made for meeting outcomesHas been piloted through state dollars - will be Medicaid funded

beginning February 1, 2013 through EPSDT

ANTIPSYCHOTICS-KEEPING IT DOCUMENTED FOR SAFETY

(A+KIDS)

Initial Experience and Findings from a State Medication Safety Registry

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Psychoactive Medication Use in Vulnerable Population ConcernsDisproportionate use of psychoactive medications in

foster populationsPossibly over-reliance on pharmacotherapy to address

behavioral concernsPsychoactive medication polypharmacy without clear

evidence basis Off-label use and limited short-term efficacy data or long-

term adverse effect studies (off-label use may be an appropriate practice in many cases)

Lack of monitoring and coordination of care

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Foster Population in NCter80% are enrolled in CCNC PCMH (increase from 31% in

October, 2011)No clinically meaningful differences in Medicaid non-

fosters and fosters in physical health indicators (asthma, diabetes, etc)

Marked differences in behavioral health indicator prevalence

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Foster Population in NCFoster recipients 3X more likely to have a mental health

diagnosis (49% versus 13%)More likely to have an intellectual disability (13% versus

5%)More likely to have PTSD (8.5% versus 0.5%)More likely to have depression (6% compared to 1%)More likely to have bipolar d/o (3.6% versus 0.3%)Differences were insignificant for schizophrenia and other

psychoses

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Foster Population in NCFoster recipients had more OP visits, spent more on Rxs,

more on mental health treatment, more on inpatient and ED visits and cost significantly more overall than non-foster Medicare children/adolescents ($9,040 versus $1,864 annually)

Foster children enrolled in a CCNC PCMH cost less than non-enrolled similar ($8,333 compared to $9,040 annual mean cost/patient)

This cost difference underscores the effort to get fosters enrolled in PCMH

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NC Response: A+KIDSWhat

Web-based safety registry system with fax optionClinical data entry at point of care by prescriberAutomated Authorization at time of submission

Provider participation is only requirementUse of “Over-rides”

No one should go without medication regardless of prescriber participation

WhoAll Medicaid Funded Youth 0-17Any antipsychotic Rx, New or RefillAll Medicaid prescribers regardless of discipline

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NC Response: A+KIDSHow

Community Care North Carolina Network InfrastructureAll Medicaid prescribers regardless of discipline or area of

practice were registeredPhased introduction (0-12, 12-17, NC Healthchoice -SCHIP)Endorsement from advocacy and stakeholder groupsClose Partnership with web development firm

Infina Connect, LLC

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A+KIDS Initial FindingsProvider ParticipationFrom April 2011-August 21, 2012

1241 prescribers with at least 1 authorization from the registry 1522 registered providers have not attempted to authorize a Rx

29,691 total authorizations15,194 total patients1842 foster children in the registry

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Meds- 35% risperidone, 25% aripiprazole, 11% quetiapine

74% of A+KIDS patients are reported to be in some form of psychotherapy

Top 5% of prescribers account for 40% of authorizations2 prescribers account for 4% of all authorizations

Top 25% of prescribers account for 81% of authorizations

A+KIDS Initial FindingsResource Utilization Features

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A+KIDS Initial FindingsParticipation

Developmen-tal Pediatrician

2%

Psychiatric NP3%

Psychiatric PA1%

Psychiatrist MD/DO61%

Non-Psychia-trist MD/DO

20%

Participating Prescriber Types After 6 Months of A+KIDS*

Developmental Pediatrician

Psychiatric Nurse Practioner

Psychiatric Physicians Assistant

Psychiatrist MD/DO

Non-Psychiatrist MD/DO

Non-Psychiatrist MD/DO(but patient also has a Psychiatrist)

Unknown

* Ages 0-12 Only

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A+KIDS Initial Findings Clinical Features

*Ages 0-17

Unspecified M

ood Disorder

Disruptive

Behavior D

isorders

ASD/P

DD

Bipolar Diso

rderADHD

Other

Psychosis

Major D

epressive

Disorder

PTSD

Agitati

on/Hyp

erkinesia

Anxiety

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Primary Dx Cited in A+KIDS Registry- First Year*

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A+KIDS Initial FindingsClinical Features

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A+KIDS Initial FindingsClinical Features-Body Mass Index

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A+KIDS Initial FindingsClinical Features-Body Mass IndexEarly Informal Comparisons, Adolescents

Source Prevalence Overweight*(%)

Prevalence Obese**(%)

NC A+KIDS, 2011-2012, (Ages 13-17)

19.6 30.6

North Carolina, 2009 (Ages 10-17)CHAMP, BRFSS

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North Carolina, 2007-2008(Ages 13-16)Medicaid Enrollees*

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*Lazorick S, Peaker B, Perrin EM, Schmid D, Pennington T, Yow A, DuBard CA. Prevention and treatment of childhood obesity: care received by a state Medicaid population. Clin Pediatric (Phila). 2011 Sep;50(9):816-26.

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A+KIDS Initial FindingsPrescribing Trends

Antipsychotic Fills Per Day Per 1000 Enrollees Ages 13-17

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Next Steps with Foster Care PopulationOngoing efforts to align foster population with

LME/MCO-CCNCShared definition of population across all state agenciesImproved descriptive statistics which characterize the

population healthcare resource utilization and risk factorsTask force at state agency level to address development

of programs to support needs of this at risk populationCase and provider profiling to identify specific follow-up

educational and/or consultative needs

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Questions?