Money Matters Webinar Objectives

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Prevention Research Centers (PRC)-Healthy Aging
Research Network (HAN) Webinar Series
Money Matters Funding and Sustaining
Evidence-Based Depression Programming
November 13, 2008 300-430 EST
Moderated by Alixe McNeill, MPA
Shelagh A. Smith, MPH, CHES
Chris Imhoff
Liz Gitter, MSSW, LISW-S
Doris Clanton, Esq., MA, JD
Not pictured
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Sponsors
Prevention Research Centers-Healthy Aging
Research Network http//www.prc-han.org/ Retirem
ent Research Foundation http//www.rrf.org/ Natio
nal Council on Aging http//ncoa.org/index.cfm
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Money Matters Webinar Objectives

• Understand successful grant funding strategies
  for training and implementation of evidence-based
  depression care management programs.
• Learn about the actions three states have taken
  to foster community start-up of Healthy IDEAS
  and PEARLS.
• Learn about public reimbursement for mental
  health services in primary care (such as IMPACT)
  and community settings.
• Learn about billing strategies for depression
  care management.
• Understand how others have funded evidence-based
  depression care so that your agency is able to
  develop funding options and plans.

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Funding for Community Depression Care Examples
Healthy IDEAS and PEARLS

• Program development and research funding
• John A. Hartford Foundation, AoA
• Dissemination funding to date
• AoA, CDC, SAMHSA, Retirement Research Foundation,
  State of Washington
• Academic partner resources through University of
  Washington and Baylor and Baylor VA work.
• State and Local implementation funding includes
• AoA, SAMHSA, CMS, AHQR, NIH,
• States, Foundations and Local Government

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Mini-grants FundHealthy IDEAS in Ohio

• Liz Gitter
• GitterL_at_mh.state.oh.us
• 614-466-9963

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What We Did

• Implemented a mental health evidence-based
  practice (EBP) in an aging Home and Community
  Based Service (HCBS funded by Medicaid) to
  seniors who met levels of care for nursing homes.
• Used funding from federal grant 3 state
  agencies to fund mini-grants for start-up costs
  for Healthy IDEAS and other EBP/promising
  practices.

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Get Buy-In

• At state level held two policy institutes
  stakeholders heard national speakers, developed
  goals with action steps and prioritized
• Asked state dept. directors to speak
• Local stakeholders aging, behavioral health,
  health, adult protective services
• Consumer and family organizations

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Older Ohioans Behavioral Health Network

• County MH/SA boards approached Ohio Dept. of
  Mental Health to address seniors as underserved
  and growing population
• Ohio received funding from SAMHSA for Mental
  Health Transformation State Incentive Grant
  (TSIG)
• TSIG supports infrastructure change

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State Collaborations

• ODMH provided initial funding with aging and
  substance abuse dept. contributing small amounts
• Six state dept. directors signed letter of
  commitment
• Established trust and learned each others
  language----i.e. depression not mental
  illness
• Created Older Ohioans Behavioral Health Network
  state human service agencies, providers,
  consumers, families http//www.oacbha.org/programs
  /older_ohioans.html
• Contact FFleischer_at_oacbha.org Frank Fleischer
• Ohio Association of County Behavioral Health
  Authorities
• 614-224-1111

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Local Collaborations

• Locals identified and secured small amounts of
  funding from additional sources (state
  departments, hospitals, foundations)
• Older Ohioans gave several rounds of mini-grants
  to 11 Area Agencies on Aging (AAA) mini-grants to
  organize local cross-system collaboratives to do
  needs assessment/resource inventory

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Mini-Grants Requirements

• Brief application (6 pages) to Older Ohioans with
  aging, MH, and consumers reviewing
• Requirements for mini-grant
• Regional collaboration MH/SA and Aging
• Evidence-based or promising practice
• Support recovery (consumer choice)
• No funding for direct services
• Awards 4,000 - 10,000 most at lower end
• (cover start-up (i.e. training only)

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Mini-Grants

• Local AAAs and MH/SAs selected EBP and promising
  practices to implement
• Healthy IDEAS
• I Team care coordination
• Web-based primary physician training on
  depression, dementia and substance abuse
• Pilot training home-health aides on MLDT
  depression and memory impairment.
• Pilot promising practice harm reduction of
  hoarding

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AAAs Implement

• Passport program implements Healthy IDEAS as part
  of assessment by nurses and social workers.
  (Passport is HCBS alternative delivered by aging
  system.)
• For identified clients, intervention by Area
  Agencies on Aging nurse or social worker as part
  of Passport
• Staff reports Healthy IDEAS great tool, decreased
  client depression, minimal change to work load.

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Sharing Across Ohio and USA

• Developed Ohio tool kit with information on CD
  and in notebooks
• Implementation staff present at statewide and
  regional aging conferences
• Reporting to SAMHSA via TSIG
• Sharing nationally through meetings and webinars

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National Healthy Ideas ResourcesNeeded for Local
Implementation

• Healthy IDEAS
• website http//careforelders.org/index.cfm?menuit
  emid290
• Contact Esther Steinberg, at Esteinberg_at_sheltering
  arms.org or 713.685.6579
• Webinar on Healthy IDEAS
• http//www.ncoa.org/content.cfm?sectionID379deta
  il260
• Thank you!

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Georgia Strategies

• Doris M. Clanton, Esq.
• dclanton_at_dhr.state.ga.us
• Georgia Department of Human Resources
• Division of Aging Services

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Background

• Georgia
• 2003 Data DHR/MHDDAD GAP Analysis older adults
  special population - underrepresented and
  underserved
• The DHR Division of Aging Services (DAS, or SUA)
  and Division of Mental Health, Developmental
  Disabilities and Addictive Diseases (MHDDAD, or
  SMHA) collaborations with the Fuqua Center for
  Late-Life Depression of the Emory Healthcare and
  others on three projects serving older adults
• CCSP Depression Screening (Healthy Ideas)
• Geriatric Telemedicine
• Older Adult Peer Support Specialists
• Atlanta Area Coalition on Aging Mental Health
• Georgia Coalition on Older Adults and Mental
  Health

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Healthy Ideas

• Georgia Department of Human Resources, Division
  of Aging Services (DAS), Community Care Services
  Program (CCSP) Depression Screening
• Statewide Depression Screening for participants
  in the Community Care Services Program Medicaid
  waiver program, 1915 (c) providing intervention
  to help (1) identify those at risk (2) identify
  areas lacking in mental health services (3)
  train care coordinators to recognize signs and
  symptoms and discuss with primary care
  physicians and (4) obtain resources to provide
  services
• Two lead care coordinators (case managers) in
  each of the 12 Planning and Service Areas (PSAs)
  trained in Healthy Ideas designated Psychiatric
  Care Specialists.
• Key Partners Fuqua Center for Late-Life
  Depression (Emory University), DHR Division of
  Aging Services (SUA), the 12 Area Agencies on
  Aging (AAAs) and their Care Coordination Agencies
• Funding Early American Foundation on Suicide
  Prevention grant provided to Atlanta Regional
  Commission AAA SUA replicated statewide,
  progressed to EBPs and Healthy Ideas, Care
  coordination state funding for training.

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PEARLS

• Two Georgia Coalition on Older Adults and Mental
  Health Member agencies funded technical
  assistance on PEARLS training at University of
  Washington (9/24-26/08)
• Central Savannah River Authority (CSRA) Area
  Agency on Aging
• Funding AAA budget, Older Americans Act funding
• Georgia Association of Homes and Services for the
  Aged (GAHSA) and the Fuqua Center for Late-Life
  Depressions
• Funding Georgia Medical Care Foundation grant to
  GAHSA for low income older adults residing in
  high rises in Metro Atlanta area, for screening,
  referral and problem-solving

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Successful Collaboration

• Georgia - Older Adults Peer Support Specialists
  Training Project
• Builds upon Georgia Consumer Mental Health
  Network training and their successful Certified
  Peer Specialist (CPS) program for older adults
  peers and consumers
• Key Partners DHR DAS (SUA), DHR MHDDAD (SMHA),
  Georgia Mental Health Consumer Network,
  Appalachian Consulting Group, and the Fuqua
  Center for Late-Life Depression
• Funding Fuqua private donor for focus group,
  small part of a CMS Real Choice Systems Change
  grant (for SMHA) used to train first volunteers

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Additional Training

• Depression and Mental Health Training Provided by
  for DHR Public Guardianship (Adult Protective
  Services case managers), GeorgiaCares (SHIP), and
  LTCO
• Partners Training provided by the Fuqua Center
  of Late Life Depression. Organizers included DAS
  GeorgiaCares, DAS Public Guardianship
• Funding State funding for public guardianship
  (DAS) and part of GeorgiaCares (SHIP) mental
  health outreach funding (5 set aside) through
  CMS
• Family Caregiver Support

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The Future

• Funding for future Healthy Ideas and PEARLS
  training
• Funding for older adult and mental health
  training, including depression training for
  Gateway (Information, Assistance and Referral)
  for Aging and Disability Resource Connection
  (ADRC)
• Would include Medicaid and Non-Medicaid programs

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Summary

• Collaborate and Partner with Others (academia,
  older adults, advocates, trailblazers, experts,
  state and local agencies, MH and Aging
  coalitions, MH Planning and Advisory Councils,
  national associations, etc.)
• Locate and Use available funding sources, even if
  small (grants, government funding, etc.)
• Identify Program Champions
• Plan for Budget Shortfalls

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• Provide for funding for Training, Retraining and
  Support for EBP pioneers
• Imbed EBPs within your program (Quality of Care)
• Plan for budget shortfalls
• Encourage advocates and Mental Health and Aging
  Coalitions to assist in acquiring funding and
  outreach

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Funding Opportunities for Depression Care
Management Washington States Experience

• Chris Imhoff
• imhofc_at_dshs.wa.gov
• 360-725-2272

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Depression Prevalence Among those served by
Washingtons AAA Network

• Based upon CES-D (11) scores, approximately 35
  (5,500) of the Medicaid LTC in-home clients over
  age 60 have indicators of minor depression
• 27 have indicators of major depression
• 20-50 of informal caregivers report depressive
  symptoms or disorders

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Funding for 1st PEARLS Project

• Development of Evidence
• University of Washington Health Promotion
  Research Center partnered with Aging and
  Disability Services of King County (AAA)
• 5-year Center for Disease Control (CDC) for
  randomized clinical trial

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How are AAAs Currently Funding PEARLS?

• Older Americans Act Funding IIIB
• Older Americans Act Funding IIIE (Family
  Caregivers)
• County Levy Funding for veterans and individuals
  with chronic health conditions
• Nursing Home Diversion Grant July 2009
• State Funding

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PEARLS Implementation Toolkit

• Mental Health Transformation Grant Funding to
  develop an implementation toolkit to facilitate
  dissemination
• University of Washingtons Health Promotion
  Research Center developed the toolkit
• Available through Washington States Aging and
  Disability Services Administration

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Future Funding Ideas - Medicaid

• 1915(c)(1) Medicaid Waiver as allowed under the
  Social Security Act
• CFR 440-180(b)(9) Other services requested by
  the agency and approved by CMS as cost effective
  and necessary to avoid institutionalization.
• Washingtons COPES waiver includes
  Recipient/Caregiver Training
• Potential to define case management as a service
  under waivers which may be a fit for specialized
  types of case management

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Future Funding Ideas OAA and Project 2020

• Authorizing language includes work on disease
  prevention and health promotion
• Potential to fund EBPs such as PEARLS or Healthy
  IDEAS

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• Public Reimbursement for
• Mental Health Services In
• Primary Care and Community Settings
• Shelagh A. Smith, MPH, CHES
• U.S. Department of Health and Human Services

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CMS/HRSA/SAMHSA Workgroup

• The New Freedom Commission on Mental Health
  Report (2003)
• Federal Action Agenda and workgroups to follow-up
  recs on financing and integration of services
  issues.
• Steps included identification of known financing
  barriers and seeking the input of those in the
  field.
• Our approach provide specific information for
  states and providers to use.

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Barriers Identified by the Expert Forum, Apply to
Medicare and Medicaid

• 1. Limitations on payments for more than one
  visit on the same day
• 2. Lack of reimbursement for components of the
  collaborative care model related to mental health
  services
• 3. Absence of reimbursement for services
  provided by some non-physician providers and
  contract providers
• 4. Medicaid disallowance of reimbursement when
  primary care providers submit bills listing a
  mental health Diagnosis corresponding
  Treatment
• 5. Low reimbursement rates in rural / urban
  settings
• 6. School-based health center settings
• 7. Lack of reimbursement incentives for
  screening preventive MH services
• See page 2-3 of Reimbursement of MH Services in
  Primary Care Settings, SAMHSA, 2008

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Primary Care Initiatives and the Collaborative
Care Model

• Providers may use evidence-based components of a
  care model. See p. 20 of SAMSHA report
• Components of Care Models may include
• Community
• Health System
• Self management support
• Delivery system design
• Decision support
• Clinical information systems
• Care Manager or Care Coordinator
• Examples of initiatives
• Robert Wood Johnsons Depression in Primary Care
  Program
• IMPACT Model for Collaborative Care (Katon, et.
  al., Diabetes Care, February 2006) See Lorig et
  al 2001 Noel et al 2004 Unutzer et al 2002)
• HRSA Bureau of Primary Health Cares Depression
  Collaborative

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Key Requests Made By Forum Participants

• Identify and disseminate successfully used mental
  health billing codes.
• Develop a project to describe specific services
  and reimbursement codes for collaborative care.
• Coordinate with States that want to develop
  contract terms for MBHOs to include PC providers
  in networks.
• Strengthen service integration, links referrals
  to specialty care settings (e.g., on-site
  consultation and referrals for rapid care).

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What Are Our Action Steps To Address The Barriers?

• Create a forum for dialogue among State Medicaid
  Directors, State Mental Health Directors, and
  Safety Net PC Providers
• Recognize States and MBHOs that appropriately
  include primary care providers in their provider
  networks.
• Describe the evidence-based components of care
  model (incl. service definitions and
  reimbursement codes).

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How to Get Collaborative Care Services Covered

• CMS pays for services, not models
• Medicaid service- State decision must be in
  State plan or under Medicaid waiver. (see p. 21
  of report and section 1915(g) of the Social
  Security Act)
• Medicare service- Bill under CPT codes via
  Evaluation and Management service code or HBAI
  codes

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Identifying Successful Codes Used in States

• States can benefit by sharing information on what
  billing strategies work
• See our website http//hipaa.samhsa.gov/hipaacod
  es2.htm
• 11 States provided the codes and providers that
  are allowed in their state to bill for MH
  services
• Level I - Current Procedural Terminology (CPT)
  Codes (AMA maintains) - Used more often by
  Medicare
• Level II - Healthcare Common Procedure Coding
  System (HCPCS) Codes (CMS maintains) - State
  Medicaid H and T codes

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CodingCPT codes

• Current Procedural Terminology
• CPT - Level I. ( AMA maintains since 1966)
• Consist of 5 numbers sometimes a 2-digit
  modifier
• Psychiatric Codes, 90801 90899, for licensed
  or certified MD and non-MD MH specialists, like
  CSW or psychologist
• Evaluation Management Codes for MDs/ NPs to use
  with ICD-9-CM diagnosis
• Health Behavior Assessment Intervention ( HBAI)
  Codes for Non-physician MH specialists, w/
  ICD-9-CM
• SBI Codes for qualified providers to conduct
  brief SU

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Claim Tips for Primary Care Providers from the
Mid-America Coalition on Health CareTip 1
Diagnosis Codes

• 311 - Depressive Disorder
• 296.90 - Mood Disorder
• 300.00 - Anxiety Disorder
• 296.21 - Major DD, Mild
• 296.22 - MDD, Moderate

• 296.30 - Major DD, Recurrent
• 309 - Adjustment Disorder with Depressed Mood
• 300.02 GAD
• 293.83 - Mood Disorder due to Medical Condition
• 314 - ADHD

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Tip 2 Evaluation and Management (E/M) CPT Codes

• MDs/NPs may use E/M CPT codes 9920199205 or
  9921199215 (Office visit codes) with a primary
  diagnosis of depression claim with any of the
  ICD-9-CM diagnosis codes above in Tip 1.
• Do not use psychiatric or psychotherapy CPT
  service codes (9080190899) with a depression
  claim for a primary care setting. These codes
  tend to be reserved for psychiatric or
  psychological practitioners only.
• (Mid-America Coalition on Health Care, 2004
  cited p.16 in Reimbursement of MH Services in
  Primary Care Settings, SAMHSA, 2008)

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States Reports of Most Successful MH Service
Codes

• The EM CPT outpatient service codes for
  consultation or office visits are to be used by
  MDs in the community care setting use with an
  ICD-9-CM primary psychiatric or medical
  diagnosis.
• EM codes Used w/ ICD-9 diagnostic code, by MDs
  or NPs
• Office 99201 99125
• Consult 99241 99255
• (--State of Arizona, Medicaid office, 2006)

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Newer Types of MH CPT Codes Used with Primary
Physical Diagnosis

• Health Behavior Assessment Intervention (HBAI)
  Used w/ ICD-9 ( Medical Primary dx) by
  non-physician Mental Health/ Behavioral
  specialist (certified by State)
• 96150 HBA interview or monitoring, 15 minutes
• 96151 Reassessment
• 96152 Individual HB Intervention, 15 minutes
• 96153 Group Intervention
• 96154 Family ( with patient)
• 96155 Family (without patient)

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CPT Level I Codes, Contd

• Screening for Substance Use and Brief
  Intervention
• 99408 (screen) 99409 (intervention) Private
  insurer
• H0049 H0050 Medicaid
• G0369 G0370 Medicare
• For a discussion of possible reasons for
  variability in interpreting claims, see pages
  26-27 of SAMHSA report.

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Resources on Billing for Collaborative Care MH
Services

• SAMHSA Website
• http//hipaa.samhsa.gov/hipaacodes2.htm
• CMS Mental Health Website
• www.cms.hhs.gov/MHS
• SAMHSA report
•  http//download.ncadi.samhsa.gov/ken/pdf/SMA08-43
  24/SMA08-4324.pdf
• Questions Shelagh.smith_at_samhsa.hhs.gov

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Shelagh.smith_at_samhsa.hhs.govThank you!
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Questions Answers
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Final PRC-HAN WebinarComing in December!
Evidence-Based Depression Care Programming and
Best Practices for Older Adults in a Public
Service Delivery Setting Mental Health Aging
Network Public Health
Speakers Stephen J. Bartels, Suzanne R.
Bosstick, Margaret Moore
Check back soon to Register at
http//ncoa.org/content.cfm?sectionID64