Oregon Conference: Transforming Care 2013 Tara Larson

1. Oregon Conference: Transforming Care 2013 Tara Larson Behavioral Health and Primary Care Integration in North Carolina January 8, 2013

2. Objectives Outline 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. 2

3. Causes of Health Disparities in Behavioral Health Medications (though problems evident BEFORE antipsychotics where available) High rates of smoking, lack of weight management/nutrition, and physical inactivity Lack of access to/utilization of preventive community healthcare, including health promotion services and resources Poverty Social isolation Separation 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 3 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.

4. 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 providers Decrease the re-hospitalization rate for primary psychiatric admissions Increase access to preventive health care to people with mh/dd/sa Increase 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 4

5. Why the Behavioral Health Initiative? CHCS Center for Health Care Strategies, Inc., Dec 2010Clarifying 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. 5

6. 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

7. 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.

8. Population Management Components for CCNC • Outreach / Education / Enrollment / Communication • Screening / Assessment / Care Plan • Risk Stratification / Identify Target Population • Patient Centered Medical Home – Evidence-based best practices and team based care • Targeted Disease and Care Management Interventions and Best Practices • Pharmacy Management, Medication Reconciliation • Behavioral Health Integration • Transitional Care • Self Management of Chronic Conditions

9. Community Care Networks

10. 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 objectives Provides oversight for quality improvement in practices Serves on the Sate Clinical Directors Committee Network Director who manages daily operations Care Managers to help coordinate services for enrollees/practices PharmD to assist with Med management of high cost patients Psychiatrist to assist in mental health integration

11. 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)

12. 1915 B/C Behavioral Health Waiver 1915 B/C Behavioral Health Waiver • Operated 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

13. Proposed Local Management Entity - Managed Care Organizations (LME-MCOs) and their Member Counties - by July 1, 2013 Central Region Eastern Region Western Region East Carolina Behavioral Health CenterPoint Human Services Apr 2012 Jan 2013 Smoky Mountain Center Alleghany Northampton Camden Currituck Jul 2012 Ashe Person Gates Rockingham Warren Surry Stokes Caswell Vance Pasquotank Hertford Halifax Perquimans Wilkes Granville Watauga Yadkin Orange Chowan Forsyth Guilford Franklin Bertie Avery Alamance Mitchell Durham Caldwell Nash Davie Yancey Alexand er Edgecombe Madison Washington Iredell Davidson Wake Martin Burke Tyrrell Dare Chatham Randolph Catawba Wilson McDowell Rowan Buncombe Beaufort Pitt Haywood Johnston Lincoln Greene Hyde Lee Swain Rutherford Cabarrus Henderson Montgomery Graham Harnett Gaston Jackson Wayne Polk Stanly Moore Lenoir Craven Cleveland Transylvania Mecklenburg Cherokee Macon Cumberland Pamlico Clay Richmond Sampson Jones Union Anson Hoke Duplin Western Highlands Network Mecklenburg Onslow Scotland Carteret Jan 2012 Feb 2013 Robeson # Sandhills Bladen Durham/ Wake/ Pender Partners Behavioral Health Management Center/ Johnston/ Cumberland (Pathways/ MH Partners/ Crossroads) Guilford Columbus New Jan 2013 Jan 2013 Dec 2012 Hanover Brunswick Eastpointe/ Coastal Care System PBH/ Alamance Caswell Oct 2011/ Southeastern Regional/ (Southeastern Center/ OCBHS) Five County Jan 2012/ Beacon Center Jan 2013 OPC Apr 2012 Jan 2013 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. 13

14. 1915b/c Waiver Goals • Improved Quality of Care • Increased Cost Benefit • Predictable Medicaid Costs (2009 $22.57 per person, 2012$ 20.88) • Combine the management of State/Medicaid Service Funds at the Community Level • Support the purchase and delivery of best practice services • Ensure that services are managed and delivered within a quality management framework • Empower 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

15. What does the MCO/LME do for Medicaid? Enroll & monitor providers (statewide) Call Center—Customer Support Make sure consumers with greatest need get connected to providers and have treatment plans (Care Coordination) Authorize “medically necessary” services Pay for mh/sa/dd services Provide education about ALL Medicaid benefits to recipients & consumers (website, mailings, seminars) Reviews, Medications, Hearings (Due Process) Gap analysis/community development CCNC collaboration

16. 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 Model Determines who takes the lead in care management Quadrants 1 and 3 – CCNC/Primary Care take lead Quadrant 2 – LME/MCO/Behavioral Health take lead Quadrant 4 – flexible sharing of responsibilities

17. Four Quadrant Care Management Model • Quadrant II: •  High MH/DD/SA health •  Low physical health complexity/risk • Quadrant I: •  Low MH/DD/SA health •  Low physical health complexity/risk • Quadrant IV: •  High MH/DD/SA health • High physical health complexity/risk • Quadrant III: •  Low MH/DD/SA health •  High physical health complexity/risk

18. Health Homes & Local Management Entities/Managed Care Organizations Continued . . . • Shared Care Management of recipients • Identification, linkage to services • Coordination of MH/SA/DD & physical health needs • Data exchange into Informatics • LME/MCOs signed data-sharing agreements with the CCNC Informatics Center • Collaboration on integrated care practices • Monthly-quarterly partnership meetings

20. 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 provider • A 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

21. Managing Complex Cases • Most 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 child • Single payment made for cost of total care (hospital, outpatient) – bundled payment • Lead entity will pay all components providing care • Incentive payments will be made for meeting outcomes • Has been piloted through state dollars - will be Medicaid funded beginning February 1, 2013 through EPSDT

22. ANTIPSYCHOTICS-KEEPING IT DOCUMENTED FOR SAFETY(A+KIDS) Initial Experience and Findings from a State Medication Safety Registry

23. Psychoactive Medication Use in Vulnerable Population Concerns • Disproportionate use of psychoactive medications in foster populations • Possibly over-reliance on pharmacotherapy to address behavioral concerns • Psychoactive 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 23

24. Foster Population in NCter • 80% 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 24

25. Foster Population in NC • Foster 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 25

26. Foster Population in NC • Foster 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 26

27. NC Response: A+KIDS • What • Web-based safety registry system with fax option • Clinical data entry at point of care by prescriber • Automated Authorization at time of submission • Provider participation is only requirement • Use of “Over-rides” • No one should go without medication regardless of prescriber participation • Who • All Medicaid Funded Youth 0-17 • Any antipsychotic Rx, New or Refill • All Medicaid prescribers regardless of discipline 27

28. NC Response: A+KIDS • How • Community Care North Carolina Network Infrastructure • All Medicaid prescribers regardless of discipline or area of practice were registered • Phased introduction (0-12, 12-17, NC Healthchoice -SCHIP) • Endorsement from advocacy and stakeholder groups • Close Partnership with web development firm • Infina Connect, LLC 28

29. A+KIDS Initial FindingsProvider Participation • From 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 authorizations • 15,194 total patients • 1842 foster children in the registry 29

30. A+KIDS Initial FindingsResource Utilization Features • 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 authorizations • 2 prescribers account for 4% of all authorizations • Top 25% of prescribers account for 81% of authorizations 30

31. A+KIDS Initial FindingsParticipation 31

32. A+KIDS Initial Findings Clinical Features *Ages 0-17 32

33. A+KIDS Initial FindingsClinical Features 33

34. A+KIDS Initial FindingsClinical Features-Body Mass Index 34

35. A+KIDS Initial FindingsClinical Features-Body Mass IndexEarly Informal Comparisons, Adolescents *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. 35

36. A+KIDS Initial FindingsPrescribing Trends Antipsychotic Fills Per Day Per 1000 Enrollees Ages 13-17 36

37. Next Steps with Foster Care Population • Ongoing efforts to align foster population with LME/MCO-CCNC • Shared definition of population across all state agencies • Improved descriptive statistics which characterize the population healthcare resource utilization and risk factors • Task force at state agency level to address development of programs to support needs of this at risk population • Case and provider profiling to identify specific follow-up educational and/or consultative needs 37

38. Questions?