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Title: Overview from the Field: Key Conceptual Models, Definition of Integrated Behavioral Health, CA IPI and CALMEND Projects Department of Health Care Services Behavioral Health Technical Workgroup 2-24-2010


1
Overview from the Field Key Conceptual Models,
Definition of Integrated Behavioral Health, CA
IPI and CALMEND ProjectsDepartment of Health
Care ServicesBehavioral Health Technical
Workgroup 2-24-2010
  • Barbara Mauer, MSW, CMC
  • MCPP Healthcare Consulting Inc.
  • Seattle, Washington

2
Overview from the Field
  • California
  • Integrated Policy Initiative (IPI) report
  • CalMEND Learning Collaborative
  • Financing
  • Paradigms
  • SPD Plans
  • Part Two
  • Financing and the Waiver
  • SPD Plans
  • Paradigms and Cost Offsets
  • Alignment with the Waiver
  • Management Models
  • Assumptions
  • Examples
  • Integration Pilots
  • Part One (Meeting 2/24)
  • Healthcare Environment
  • Universal Coverage/Parity
  • Service Delivery Redesign
  • Importance of MH/SU conditions
  • Patient-centered medical homes
  • Care management
  • The Care Model
  • Integrated Primary Care/MH/SU
  • Person-centered healthcare homes
  • Definition of integrated healthcare
  • Models for clinical care
  • Four Quadrant model

3
  • Part One

4
Universal Coverage/Parity Will Likely Improve
MH/SU Access and Available Services
  • Mental Health and Substance Use Services must be
    provided at parity with general healthcare
    services (no discrimination)
  • Large Employers (Parity Act)
  • Medicaid (Parity Act Reform Legislation)
  • Health Insurance Exchanges for Individual and
    Small Group Policies (Health Reform Legislation)
  • Medicare on the way (Medicare Modernization Act
    of 2003)
  • But... the parity regulations may not be the most
    important component if health reform passes keep
    your eye on the Benchmark Benefit Package that
    s currently in the Senate bill
  • In Medicaid most/all enrollees may be guaranteed
    a benchmark benefit package that at least
    provides essential health benefits
  • Mental Health and Substance Use are included in
    the definition of essential health benefits

4
5
Service Delivery Redesign MH/SU Conditions are
Now on the Health Policy Communitys Radar
Screen
  • 49 of Medicaid beneficiaries with disabilities
    have a psychiatric illness (this is new
    information previous studies that excluded
    pharmacy claims calculated the rate at 29)
  • Substance use conditions do not show up in this
    study at the expected levels because its based
    on an analysis of claims and pharmacy scripts

The Faces of Medicaid III Refining the Portrait
of People with Multiple Chronic ConditionsCenter
for Health Care Strategies, Inc., October 2009
6
Service Delivery Redesign MH/SU Conditions are
Now on the Health Policy Communitys Radar
Screen
  • Morbidity and Mortality in People with Serious
    Mental Illness
  • Persons with serious mental illness (SMI) are
    dying earlier than the general population
    (average age of death is 53)
  • While suicide and injury account for about 30-40
    of excess mortality, 60 of premature deaths in
    persons with schizophrenia are due to medical
    conditions such as cardiovascular, pulmonary and
    infectious diseases (NASMHPD, 2006)
  • OR state study found that those with
    co-occurring MH/SU disorders were at greatest
    risk (45.1 years)

7
Service Delivery Redesign Patient-Centered
Medical Homes (PCMH)
  • 45 percent of Americans have one or more chronic
    conditions.
  • Over half of these people receive their care from
    3 or more physicians.
  • Treating these conditions account for 75 of
    direct medical care in the U.S.
  • PCMH, with care management, is a key strategy

8
Service Delivery Redesign PCMH Principles
  • Ongoing Relationship with a PCP
  • Care Team who collectively take responsibility
    for ongoing care
  • Provides all healthcare or makes Appropriate
    Referrals
  • Care is Coordinated and/or Integrated
  • Quality and Safety are hallmarks
  • Enhanced Access to care is available
  • Payment appropriately recognizes the Added Value
  • See the www.pcpcc.net site for more information

9
Service Delivery Redesign Care Management
  • Care management is a multidimensional activity
    with models ranging in level of intensity and
    breadth of scope (key components of care
    management include patient identification
    individual assessment of risks/needs care
    planning with patient/family teaching
    patient/family about management of disease(s)
    coaching patient/family tracking over time and
    revising care plan as needed).
  • Studies of care management in primary care show
    convincing evidence of improving quality however
    it takes time to realize these quality outcomes
    (e.g., 12 months is probably not enough time).
  • Care management studies in primary care are mixed
    regarding reductions in hospital use and
    healthcare costs (two promising studies included
    emphasis on training of care manager team, care
    management panel sizes at reasonable levels,
    close relationships between care managers and
    PCPs, and interactions with patients in-clinic,
    at home and by telephone).

10
Service Delivery Redesign Care Management
  • Selecting the right patients for care management
    is associated with reducing costs and improving
    quality (e.g., individuals who need end-of-life
    care need different services).
  • Training of care managers is an important factor
    in the success or failure to reduce costs and
    improve quality.
  • Successful programs have care managers as part of
    multidisciplinary teams that involve physicians.
  • Presence of family caregivers improves success of
    care management, and use of coaching techniques
    is a viable approach.
  • The intensity of the care management needed for
    success in improving quality and reducing costs
    is unclear.
  • Bodenheimer T, Berry-Millett R. Care management
    of patients with complex health care needs Robert
    Wood Johnson Foundation Research Synthesis Report
    No. 19. December 2009. www.policysynthesis.org

11
Service Delivery Redesign Overall Model for
Improving Primary Care (CALMEND version)
12
Integrated Care Patient-Centered Medical Homes
become Person-Centered Healthcare Homes
  • Person-Centered Healthcare Home
  • Not a clear articulation in the PCMH model of the
    role of MH/SU
  • Change to Person Centered Healthcare Home signals
    that MH/SU is a central part of healthcare and
    that healthcare includes a focus on supporting
    goals for improved self management
  • Use a bi-directional approach to address the
    integration of primary care services in MH/SU
    settings as well as the need for MH/SU services
    in primary care settings
  • Build in the care manager/ behavioral health
    consultant and consulting prescriber functions
    that have proven effective in the IMPACT model
    and mirror this model to bring planned primary
    care into MH/SU settings
  • PCMH Principles
  • Ongoing Relationship with a PCP
  • Care Team who collectively take responsibility
    for ongoing care
  • Provides all healthcare or makes Appropriate
    Referrals
  • Care is Coordinated and/or Integrated
  • Quality and Safety are hallmarks
  • Enhanced Access to care is available
  • Payment appropriately recognizes the added value

13
Integrated Care Recent Reports
  • World Health Organization
  • Integrating Mental Health Into Primary Care A
    Global Perspective (Fall 2008)
  • http//www.who.int/mental_health/resources/mentalh
    ealth_PHC_2008.pdf
  • Agency for Healthcare Research and Quality
  • Integration of Mental Health/Substance Abuse and
    Primary Care (Fall 2008)
  • http//www.ahrq.gov/clinic/tp/mhsapctp.htm  
  • Hogg Foundation for Mental Health  
  • Connecting Body and Mind A Resource Guide to
    Integrated Health Care in Texas and the United
    States (Fall 2008)
  • http//www.hogg.utexas.edu/programs_RLS15.html  

14
Integrated Care A Definition
  • It has been defined in many ways, but in essence
    integrated healthcare is the systematic
    coordination of physical and behavioral health
    care. The idea is that physical and behavioral
    health problems often occur at the same time.
    Integrating services to treat both will yield the
    best results and be the most acceptable and
    effective approach for those being served The
    question is not whether to integrate, but how.
    Neither primary care nor behavioral health
    providers are trained to address both issues.
  • Hogg Foundation for Mental Health

15
Integrated Care The Models for Clinical Care
  • Co-location
  • House BH specialists and primary care providers
    in same facility, supporting warm hand-off
  • Does not ensure that providers collaborate in
    treatment this may vary greatly across clinics
  • Research is somewhat limitedsimply placing a BH
    specialist in PC is unlikely to improve patients
    outcomes unless care is coordinated and based in
    evidence-based approaches
  • Primary Care Behavioral Health Model
  • BH consultant serves as consultant to PCP,
    focusing on optimizing the PCPs quality of BH
    care for patients
  • Targets behavioral issues related to medical
    diagnoses instead of traditional BH problems like
    depression and anxiety
  • Has not yet been systematically
    evaluatedalthough likely beneficial, the
    effectiveness of the model is not yet known

16
Integrated Care The Models for Clinical Care
  • Collaborative Care
  • Adaptation of the chronic care model for
    psychiatric disorders, used stepped care to treat
    depression, anxiety disorders, bipolar disorder
  • Integration of BH care manager and consulting
    psychiatrist into PC setting, with registry to
    track and monitor response to treatment
  • Numerous studies of clinical and cost
    effectiveness, with adolescents, adults, and
    older adults, with and without co-morbid medical
    illnesses and from different ethnic
    groupssignificant research evidence
    demonstrates that collaborative care improves
    outcomes for a wide range of patients
  • This is the model the Hogg Foundation has been
    implementing in a number of Texas PC clinics
  • Hogg Foundation for Mental Health

17
The National Councils Four Quadrant Clinical
Integration Model (MH/SU)
18
  • Focus Quadrants I and III

19
Primary Care and Depression
  • Most PCPs do a good job of diagnosing and
    beginning treatment for depression (studied 1,131
    patients in 45 primary care practices across 13
    states)
  • PCPs do less well following up with treatment
    over time
  • Less than half of patients completed a minimal
    course of medications or psychotherapy
  • Few patients who dont respond to initial
    treatment get adequate changes in treatment or
    referrals to specialists
  • Lowest quality of care among those with the most
    serious symptoms, including those with evidence
    of suicide or substance use
  • Our finding of low rates of referral to mental
    health specialists for complex patients is
    typically addressed in collaborative care
    interventions through stepped care (e.g. ,
    IMPACT) that prioritizes mental health specialist
    referrals on the basis of need.
  • Hepner et al, Ann Int Med, 9/07

20
Bipolar Disorder in Clinical Populations
Patients Treated for Depression in a Family
Medicine Clinic
Screened positive for bipolar disorder 21
649 outpatients receiving treatment for
depression
Bipolar prevalence among 649 depressed patients
27.9
MDQ sensitivity 58, specificity 93 based
on SCID for DSM-IV
Using the Mood Disorder Questionnaire
(MDQ)Hirschfeld RM, et al. J Am Board Fam Pract.
200518233-239.
21
SU Conditions are Relevant for Primary Care
  • SU conditions are prevalent in primary care
  • Tens of millions (McClellan)
  • 21 (Willenbring)
  • SU conditions add to overall healthcare costs,
    especially for Medicaid
  • SU conditions can cause or exacerbate other
    chronic health conditions
  • SU interventions can reduce healthcare
    utilization and cost

22
Primary Care and SU Services
  • Diffusion of screening and brief intervention
    (SBI) is underway
  • Motivational interviewing with fidelity should be
    a consistent component of SBI
  • Repeated BI in primary care is a promising
    practice
  • Medication-assisted therapies in primary care can
    be expanded

23
IMPACT Collaborative Care in Primary Care
23
24
IMPACT Doubles the Effectiveness of Usual Care
for Depression
50 or greater improvement in depression at 12
months

Participating Organizations
Unutzer et al., JAMA 2002 Psychiatr Clin N
America 2005
25
Washington State GA-U Project(General Assistance
Unemployable)
DSHS GA-U Clients Challenges and Opportunities
August 2006
26
GAU Goal Collaborative Care
6 FQHC systems (26 clinic sites), 10 mental
health agencies, the safety net health plan, the
RSN and UW
CMHC Level II Care
GA-U Client
PCP
CSO (benefits)
Consulting Psychiatrists
Care Coordinator
DVR (employment)
Other clinic-based mental health providers
Substance Use Treatment
Level I Care
Available in some clinics
27
Washington State GA-U Project (First Year
Findings)
  • Clients with follow up within 4 weeks of initial
    assessment
  • Level I 42 (range across clinics 32-64)
  • Clients with Psychiatrist Consultation
  • Level I 31 (range across clinics 20-83)
  • Level I outcomes 12 weeks after initial
    assessment
  • Clients with PHQ-9 score improved at least 50
    over 12 weeks 20 (range across clinics
    12-28)
  • Clients with GAD-7 score improved at least 50
    over 12 weeks 20 (range across clinics
    13-26)
  • Quality Improvement effort, with attention to
    core components/workflow
  • High rates of engagement (100) and 4 week
    follow-up (93)
  • Effective use of in-person and telephone contacts
  • Psychiatric Consultation at 60
  • 63-72 with substantial (gt50 ) clinical
    improvement

Unutzer. University of Washington
28
Washington State GA-U Project
  • Removing many of the barriers commonly identified
    (finance, regulation, sharing of information) did
    not remove the cultural differences, historic
    lack of trust, or the challenges of implementing
    evidence-based practices
  • While all of the usual suspect barriers must be
    addressed, the most formidable is changing
    practice in the field
  • There was significant variation in work processes
    across PC and MH clinics and in implementation of
    the care coordinator role across PC clinics
  • This created variation in client follow up and
    use of psychiatric consultation
  • This reduced ability to provide stepped care and
    lack of fidelity to the stepped care model, and
    negatively impacted outcomes
  • However, client outcomes were positively impacted
    by greater fidelity to the model

29
The Person-Centered Healthcare Home Q I and III
  • Incorporate the lessons of the IMPACT model,
    explicitly building into the medical home the
    care manager/ behavioral health consultant (MH
    and SU competent) and consulting prescriber
    functions that have proven effective in the
    IMPACT model
  • DIAMOND project in MNmonthly case rate payments
    for covering these components in primary care
    practices, all major payors participating
  • All healthcare is localworking out the details
    of who does what, for what levels of MH/SU
    services (Intermountain model), has to engage
    local partnershipsthe California IPI Continuum
    is a guide for these dialogues
  • http//www.cimh.org/Services/Special-Projects
    /Primary-Care/Initiative-Feedback.aspx

29
30
  • Focus Quadrants II and IV

31
Massachusetts Study Deaths from Heart Disease by
Age Group/DMH Enrollees with SMI Compared to
Massachusetts 1998-2000
2.2RR
4.9RR
1.5RR
3.5 RR
32
CATIE Study
CATIE source for SMI data NHANESIII source for
general population data Meyer et al., Presented
at APA annual meeting, May 21-26, 2005. McEvoy
JP et al. Schizophr Res. 2005(August 29).
33
CATIE Study
  • At CATIE baseline
  • 88 of subjects who had dyslipidemia
  • 62.4 of subjects who had hypertension
  • 30.2 of subjects who had diabetes
  • WERE NOT RECEIVING TREATMENT FOR THESE CONDITIONS

34
Bi-directional Primary Care/MH/SU Services
  • Many individuals served in specialty MH/SU have
    no PCP
  • Health evaluation and linkage to healthcare can
    improve MH/SU status
  • On-site services are stronger than referral to
    services
  • Housing First settings can wrap-around MH, SU and
    primary care by mobile teams
  • Person-centered healthcare homes can be developed
    through partnerships between MH/SU providers and
    primary care providers
  • Care management is a part of MH/SU specialty
    treatment and the healthcare home

35
The Person-Centered Healthcare Home Partnership
  • Assure regular screening and registry
    tracking/outcome measurement for all MH /SU
    consumers
  • Locate medical NPs/PCPs in MH/SU settingsprovide
    routine primary care services in the MH/SU
    setting via staff out-stationed under the
    auspices of a full scope person-centered
    healthcare home MH/SU organization hiring a nurse
    practitioner directly, without the backup of a
    skilled PCP and a full scope healthcare home
    cannot be described as providing a healthcare
    home, and is not a recommended pathway
  • Identify a primary care supervising physician
    within the full scope healthcare home to provide
    consultation on complex health issues
  • Assign nurse care managers to support individuals
    with elevated levels of glucose, lipids, blood
    pressure, and/or chronic medical conditions
  • Use evidence-based preventive care practices,
    adapting these practices for use in the MH/SU
    system (immunizations, cancer screening, etc.)
  • Create wellness programs that use peer counselors

36
California The Primary Care, Mental Health, and
Substance Use Services Integration Policy
Initiative (IPI)
  • Vision Overall health and wellness is embraced
    as a shared community responsibility
  • To achieve individual and population health and
    wellness (physical, mental, social/emotional/
    developmental and spiritual health), healthcare
    services for the whole person (physical, mental
    and substance use healthcare) must be
  • seamlessly integrated
  • planned for and provided through collaboration at
    every level of the healthcare system, as well as
    coordinated with the supportive capacities within
    each community

36
37
California IPI Principles (Additional Handout)
  • Ten principles introduce the expectation that
    planning and implementation ensure that
  • Each individual has a person-centered healthcare
    home, which provides mental health (MH) and
    substance use (SU) services in the primary care
    setting or primary care services in the MH/SU
    setting.
  • Each community has established a Collaborative
    Care Mental Health/Substance Use Continuum (the
    IPI Continuum). The IPI Continuum is a framework
    for service development that identifies
    population need across MH/SU levels of
    risk/complexity/acuity and assigns provider
    responsibilities within any given community for
    delivering those services. The community dialogue
    to establish the Continuum should result in
    mechanisms for stepped MH/SU healthcare back and
    forth across the Continuum, mechanisms to address
    the range of physical health risk/complexity/acuit
    y needs of the population, and collaborative
    links between the integrated healthcare system
    and other systems, community services and
    resources.
  • Measurement is aligned to support the IPI
    Continuum, Quality Improvement and fidelity
    implementation of proven models as well as
    evaluation of emerging models, with
    accountability, transparency and measures matched
    to the levels of the Continuum.

37
38
California IPI Continuum
38
39
California CalMENDJoint Project of DHCS and DMH
  • State agencies working together to use the Care
    Model and use the IHI Breakthrough Series
    Learning Collaborative model to make major rapid
    changes that produce significant breakthrough
    results and sustained use of these changes
  • Pilot Collaborative will bring together mental
    health and primary care practitioners Orange
    County, San Diego County, San Mateo County and
    Santa Clara County
  • CalMEND Primary Care and Mental Health
    Integration Change Package developed over the
    last year includes change concepts that
    operationalize the Care Model and integrated care
  • Health Care Organization
  • Delivery System Design
  • Decision Support
  • Clinical Information system
  • Community

40
California CalMENDJoint Project of DHCS and DMH
41
Financing Paradigms
  • How will funds in other systems be integrated to
    support clinical integration?
  • We need a new paradigmnone of the old models
    (Carve-in or Carve-out) work for implementing
    bidirectional integrated care for the whole
    population
  • Lessons from the field
  • Medical Home Pilots case rate in addition to
    FFS, to cover prevention, care management of
    chronic medical conditions (why not build the BHC
    in PC role into the case rate?)
  • MNfinancing the DIAMOND case rate (for BH in PC)
    out of the healthcare side (rather than the
    mental health side) believing that cost and
    quality improvements will be there
  • WA General Assistance projectexplicit stepped
    care model that finances both Level 1 (primary
    care) and Level 2 (specialty) MH/SU benefits
    dedicated financing for Levels 1 and 2 neither
    draw on dedicated mental health funding
  • Washtenaw Co, MIglobal budget for Medicaid
    population local consolidation of medical and
    behavioral health funding streams

42
Financing Paradigms
  • Assuming that parity will be embedded as a
    requirement for most health plans in the final
    healthcare reform legislation and a broader
    behavioral health benefit will be available for
    most people with coverage, and
  • Drawing on the California Integration Policy
    Initiative framework of Mild, Moderate, Serious
    and Severe Levels of Care, and

For example, the SPD plans should have a MH/SU
benefit for primary care-based brief services
42
43
Financing SPD Plans
  • Ensure that the MH/SU community and consumers
    know about the consumer protections proposed in
    the California Healthcare Foundation 2005
    report Performance Standards for Medi-Cal
    Managed Care Organizations Serving People with
    Disabilities and Chronic Conditions
  • http//www.dhcs.ca.gov/provgovpart/Pages/Technica
    lWorkgroupSPDs.aspx
  • Consider overall recommendations for SPD Plans
  • Capitation rates that cover adequate (e.g.,
    Medicare) reimbursement rates for primary care
    FFS
  • Capitation rates that include funding for a PMPM
    case rate payment to medical homes for care
    management activities
  • Capitation rates that include funding for a PMPM
    case rate for brief MH/SU services provided in
    primary care (e.g., behavioral health
    consultant/care manager and consulting
    psychiatrist )

44
  • Part Two

45
Financing SPD Plans
  • Ensure that the MH/SU community and consumers
    know about the consumer protections proposed in
    the California Healthcare Foundation 2005
    report Performance Standards for Medi-Cal
    Managed Care Organizations Serving People with
    Disabilities and Chronic Conditions
  • http//www.dhcs.ca.gov/provgovpart/Pages/Technica
    lWorkgroupSPDs.aspx
  • Consider overall recommendations for SPD Plans
  • Capitation rates that cover adequate (e.g.,
    Medicare) reimbursement rates for primary care
    FFS
  • Capitation rates that include funding for a PMPM
    case rate payment to medical homes for care
    management activities
  • Capitation rates that include funding for a PMPM
    case rate for brief MH/SU services provided in
    primary care (e.g., behavioral health
    consultant/care manager and consulting
    psychiatrist )

46
Financing Paradigms
  • Assuming that parity will be embedded as a
    requirement for most health plans in the final
    healthcare reform legislation and a broader
    behavioral health benefit will be available for
    most people with coverage, and
  • Drawing on the California Integration Policy
    Initiative framework of Mild, Moderate, Serious
    and Severe Levels of Care, and

For example, the SPD plans should have a MH/SU
benefit for primary care-based brief services
46
47
IMPACT Lowers Total Health Care Costs
/ year
Grypma, et al General Hospital Psychiatry, 2006
48
Washington State Studies of SU and Healthcare
Costs
  • Medicaid medical expenses prior to specialty SU
    treatment and over a five-year follow up were
    compared to Medicaid expenses for the untreated
    population.
  • For the Supplemental Security Income (SSI)
    population, Washington studied the Medicaid cost
    differences for those who received treatment and
    those who did not.
  • Average monthly medical costs were 414 per month
    higher for those not receiving treatment, and
    with the cost of the treatment added in, there
    was still a net cost offset of 252 per month or
    3,024 per year.
  • The net cost offset rose to 363 per month for
    those who completed treatment.
  • Providing treatment for stimulant
    (methamphetamine) addiction resulted in higher
    net cost savings (296 per month) than treatment
    for other substances. For SSI recipients with
    opiate-addiction, cost offsets rose to 899 per
    month for those who remain in methadone treatment
    for at least one year.
  • In the SSI population, average monthly Emergency
    Department (ED) costs were lower for those
    treatedthe number of visits per year was 19
    lower and the average cost per visit was 29
    lower, almost offsetting the average monthly cost
    of treatment.
  • For frequent ED users (12 or more visits/year)
    there was a 17 reduction in average visits for
    those who entered, but didnt complete SU
    treatment and a 48 reduction for those who did
    complete treatment.

49
Kaiser Permanente Northern California Studies
  • The setting was an internally operated outpatient
    and day treatment SU program in which primary
    care was added
  • Kaiser tracked a subgroup of patients with
    Substance Abuse-Related Medical Conditions
    (SAMCs) which included depression, injury and
    poisonings/overdoses, anxiety and nervous
    disorders, hypertension, asthma, psychoses,
    acid-peptic disorders, ischemic heart disease,
    pneumonia, chronic obstructive pulmonary disease,
    cirrhosis, hepatitis C, disease of the pancreas,
    alcoholic gastritis, toxic effects of alcohol,
    alcoholic neuropathy, alcoholic cardiomyopathy,
    excess blood alcohol level, and prenatal alcohol
    and drug dependence
  • Many of these are among the most costly
    conditions to the health plan
  • Focusing on the SAMC subgroup, they found that
    SAMC integrated care patients had significantly
    higher abstinence rates than SAMC independent
    care patients
  • SAMC integrated care patients demonstrated a
    significant decrease in inpatient rates while
    average medical costs (excluding addiction
    treatment) decreased from 470.39 PMPM to 226.86
    PMPM.

50
Align with 1115 Concept Paper
  • Key Objectives
  • Bring the majority of Duals and ABD(SPD) now in
    FFS into Managed Care
  • Bring the CCS Youth into Managed Care
  • Bring the Rest of TANF into Managed Care
  • Expand the Medi-Cal box by bringing more
    Indigent/ Uninsured into Managed Care
  • Note Most of the costs are in the FFS Dual
    FFS ABD boxes
  • Population Focus

50
51
Align with 1115 Concept Paper
  • Four Area of Fragmentation
  • Managed Care population fragmentation between
    health, MH and SU
  • FFS population no integration of primary, acute,
    SU, MH, social long-term care mix of services
    paid and administered by different systems
  • CCS (Youth) fragmentation
  • Medi-Medi fragmentation

51
52
Align with 1115 Concept Paper
  • Organized Delivery Systems of Care
  • Key Objectives
  • Rely on existing Managed Care Plans provided
    such plans can meet the needs of the population
    and achieve the States performance standards
  • Bring in new Managed Care plans as necessary and
    appropriate the meet diverse geographic and
    population needs
  • Translation If youre in a county with high Mg
    Care penetration, start coordinating and/or
    partnering If youre in a county with little or
    no Mg Care, join the planning process to make it
    happen ASAP

The MH/SU systems have an important contribution
to make to this process!
52
53
Payment Reform Models Link to the Ability to
Demonstrate Outcomes and Manage Costs
  • New funding mechanisms will be utilized to fund
    services that manage total healthcare
    expenditures
  • Many PCMHs will be funded with a 3-layer
    modelnow being piloted
  • Payment for inpatient care will bundle hospital
    and physician services that only pay for part of
    Potentially Avoidable Complications (PACs)
  • Bundled payments may include all costs in the 30
    days post an inpatient stay, including any return
    to the hospital

53
54
Management Models to Consider
  • Acknowledging that all healthcare is local, we
    have identified three models of integration that
    build on existing designs in the California
    Counties
  • Single County Organized Health System Model (8
    counties)
  • County Organized Health System Private Health
    Plan Model (9 counties)
  • Small County Collaboration Model (31 counties)
  • All three models are organized aroundthe idea
    that each county would havean integrated design
    for the four Priority Populations (at a
    minimum)identified in the Waiver ConceptPaper,
    bringing current MediCal FFS populations into
    managed care and expanding coverage for indigent
    uninsured

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Management Model Assumptions
  • Each Model assumes that
  • Structures are put in place to support and ensure
    that the clinical activities mirror the
    healthcare reform goals of Improving Quality and
    managing Total Healthcare Expenditures
  • Substance use, mental health and primary care
    services will be clinically integrated and the
    financial and management structure will support
    clinical integration, versus hinder it (e.g., pay
    for same day services, etc.)
  • Services will be provided through an Organized
    Delivery System of Care (managed care) that
    operates within a quality improvement and
    performance measurement structure using the IPI
    Continuum as the framework for developing a
    collaborative delivery system that includes all
    levels of care
  • The Management Structure will seamlessly manage
    both Medicaid and non-Medicaid funds and services

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Single County Organized Health System Model
  • 8 Counties - Yolo, Monterey, Santa Cruz, Santa
    Barbara, San Luis Obispo, Orange, Merced, and San
    Mateo
  • Current components could support an integration
    effort involving the County Mental Health
    Department, Alcohol Drug Program, Medically
    Indigent Service Program (MISP) and Public Entity
    Medi-Cal Managed Care Plan (PEMMCP)
  • Could serve as an organized system of care for
    the priority populations (at a minimum) to
    address their healthcare, mental health and
    substance use needs in an integrated manner

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Single County Organized Health System Model
  • These counties could create an integrated
    clinical design based on person-centered
    healthcare home principles
  • And develop one of the following financial and
    management designs

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All of the Models...
  • Would be built around an integrated clinical
    design based on person-centered healthcare home
    principles combined with one of the financial
    and management designs and a shared savings pool
    across medical, MH and SU

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Integration Pilots
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  • Contact Information
  • Barbara J. Mauer, MSW CMC
  • barbara_at_mcpp.net
  • 206-613-3339
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