Section 2703: State Option to Provide Health Homes for Enrollees with Chronic Conditions

1. Section 2703: State Option to Provide Health Homes for Enrollees with Chronic Conditions Division of Integrated Health Systems Disabled and Elderly Health Programs Group Center for Medicaid and CHIP Services Centers for Medicare & Medicaid Services

2. Background Section 2703 adds section 1945 to the Social Security Act to allow States to elect this option under the Medicaid State plan. Health Home benefit provides a comprehensive system of care coordination for Medicaid individuals with chronic conditions. Health Home providers will coordinate all primary, acute, behavioral health and long term services and supports to treat the “whole-person”.

3. Health Home Service Delivery Model The health home is an important option for providing a cost-effective, longitudinal “home” to facilitate access to an inter-disciplinary array of medical care, behavioral health care, and community-based social services and supports for both children and adults with chronic conditions.

4. Goals for Health Homes Our goal /expectation for Health Homes will result in … • improved quality of care/outcomes for individuals; • improved experience of care for beneficiaries; • reduction in hospital admissions and readmissions; • reduction in ER use; • less reliance on LTC facilities and • reduction in overall health care costs.

5. Health Home Models States may expand upon the traditional and existing medical home models to build linkages to community & social supports, and to enhance the integration and coordination of medical, behavioral, and long-term care or develop new models

6. Key Features • Coordination of primary, acute, behavioral health, and long-term services & supports • Whole-person perspective • Person-centered Care Planning • Multi-disciplinary team approach • Available to all categorically needy with selected chronic conditions • May target geographically

7. Eligibility Criteria • Medicaid eligible individual having: • two or more chronic conditions, • one condition and the risk of developing another, • or at least one serious and persistent mental health condition.

8. Chronic Conditions in 2703 • The chronic conditions listed in statute include: • mental health condition, • substance abuse disorder, • asthma, • diabetes, • heart disease, and • being overweight (as evidenced by a BMI of > 25). • Through Secretarial authority, States may add other chronic conditions in their State Plan Amendment for review and approval by CMS.

9. Health Home Services • Comprehensive Care Management; • Care coordination; • Health promotion; • Comprehensive transitional care from inpatient to other settings; • Individual and family support; • Referral to community and social support services; • Use of health information technology, as feasible and appropriate.

10. Health Home Provider Types Designated providers as defined in 1945(h)(5), May be physician, clinical/group practice, rural health clinic, community health center, community mental health center, home health agency, pediatrician, OB/GYN, other. Team of health care professionals in 1945(h)(6), May include physician, nurse care coordinator, nutritionist, social worker, behavioral health professional, and can be free standing, virtual, hospital-based, community mental health centers, etc. Health team in 1945(h)(7) (as defined in section 3502) Must include medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral health providers, chiropractics, licensed complementary and alternative care provider

11. Health Home Providers • As noted in the November 16, 2010 SMD letter Health Home providers are expected to address several functions including, but not limited to: • Providing quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services; • Coordinating and providing access to high-quality health care services informed by evidence-based guidelines; • Coordinating and providing access to mental health and substance abuse services; • Coordinating and providing access to long-term care supports and services. • States are responsible for monitoring as well as supporting HH providers to be true to the HH model.

12. Provider Expectations • Provide quality-driven, cost-effective, culturally appropriate, and person- and family-centered health home services; • Coordinate and provide access to high-quality health care services informed by evidence-based clinical practice guidelines; • Coordinate and provide access to preventive and health promotion services, including prevention of mental illness and substance use disorders; • Coordinate and provide access to mental health and substance abuse services; • Coordinate and provide access to comprehensive care management, care coordination, and transitional care across settings. Transitional care includes appropriate follow-up from inpatient to other settings, such as participation in discharge planning and facilitating transfer from a pediatric to an adult system of health care; • Coordinate and provide access to chronic disease management, including self-management support to individuals and their families; • Coordinate and provide access to individual and family supports, including referral to community, social support, and recovery services; • Coordinate and provide access to long-term care supports and services; • Develop a person-centered care plan for each individual that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services; • Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate; and • Establish a continuous quality improvement program, and collect and report on data that permits an evaluation of increased coordination of care and chronic disease management on individual-level clinical outcomes, experience of care outcomes, and quality of care outcomes at the population level.

13. Enhanced Federal Match • There is an increased federal matching percentage for the health home services of 90 percent for the first eight fiscal quarters that a State plan amendment is in effect. • The 90 percent match does not apply to other Medicaid services a beneficiary may receive.

14. Enhanced Federal Match Additional periods of enhanced 90% FMAP would be allowed for new individuals served through either • a geographic expansion of an existing health home program, or • separate health home designed for individuals with different chronic conditions. • It is important to note that States will not be able to receive more than one 8-quarter period of enhanced FMAP for each health home enrollee. 

15. HH Reporting Requirements Provider Reporting • Designated providers of health home services are required to report quality measures to the State as a condition for receiving payment. State Reporting • States are required to collect utilization, expenditure, and quality data for an interim survey and an independent evaluation. Reports to Congress • Survey of States & Interim Report to Congress 2014 • Independent Evaluation & Report to Congress 2017

16. Health Home Quality Reporting Strategy Health Home providers are required to report to the State on all applicable quality measures as a condition for receiving payment. • Core Measure Set • State Specific Goals and Measures

17. Health Home Core Measure Set • Adult BMI Assessment • Ambulatory Care-Sensitive Condition Admission • Care Transition – Transition Record Transmitted to Health care Professional • Follow-Up After Hospitalization for Mental Illness • Plan- All Cause Readmission • Screening for Clinical Depression and Follow-up Plan • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

18. Health Home Core Measure Set • Adult BMI Assessment • Percentage of members 18-74 years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year

19. Health Home Core Measure Set • Ambulatory Care-Sensitive Condition Admission • Ambulatory care sensitive conditions: age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years.

20. Health Home Core Measure Set 3. Care Transition – Transition Record Transmitted to Health care Professional • Care transitions: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge.

21. Health Home Core Measure Set 4. Follow-Up After Hospitalization for Mental Illness • Mental health: percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge.

22. Health Home Core Measure Set 5. Plan- All Cause Readmission • For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.

23. Health Home Core Measure Set 6. Screening for Clinical Depression and Follow-up Plan • Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool AND follow-up documented

24. Health Home Core Measure Set 7. Initiation and Engagement of Alcohol and Other Drug Dependence Treatment • Percentage of adolescents and adults members with a new episode of alcohol or other drug (AOD) dependence who received the following: • Initiation of AOD treatment. • Engagement of AOD treatment.

25. Other Data Reporting Requirements States are required, by statute, to report to CMS on ongoing monitoring activities to include but not limited to service utilization rates, institutional admissions, ED visits, cost savings, use of HIT, and the nature, extent, and use of the Health Homes state plan option as it pertains to particular concepts of interest to inform the 2014 survey and ultimately the 2017 report to congress.

26. Survey and Interim Report-2014 • Hospital admission rates • Chronic disease management • Coordination of care for individuals with chronic conditions • Assessment of program implementation • Processes and lessons learned • Assessment of quality improvements and clinical outcomes • Estimates of cost savings

27. Independent Evaluation- 2017 Independent Evaluation is to be conducted for the purpose of determining the effect of the Health Homes state plan option on: • Reducing hospital admissions • Reducing emergency room visits • Reducing admissions to skilled nursing facilities

28. Status of Health Home SPAs States with Approved SPA as of March 2012: • Missouri (two Approved SPAs) • Rhode Island (two Approved SPAs) • New York • Oregon States with SPAs on the Clock: • North Carolina • Iowa Draft Proposals: Alabama, Ohio, Oklahoma, West Virginia, Maine, Idaho

29. Health Home Planning Requests States can access Title XIX funding using their FMAP rate methodology to engage in planning activities aimed at developing and submitting a State plan amendment.

30. Approved Health Home Planning Requests Alabama Arkansas Arizona California District of Columbia Idaho Maine Mississippi Nevada New Jersey New Mexico North Carolina Washington, West Virginia, Wisconsin

31. Technical Assistance • CMS -Health Home team and the Integrated Care Resource Center (ICRC) provide technical assistance to States interested in submitting a State plan amendment. • CMS continues to collaborate with Federal partners, including SAMHSA, ASPE, HRSA, and AHRQ, to ensure an evidence-based approach and consistency in implementing and evaluating the provision.

32. Additional Information • Health Homes State Medicaid Director Letter http://www.medicaid.gov/SMDL/SMD/list.asp • Health Homes information on Medicaid.gov http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html • Health Homes mailbox for any questions or comments - healthhomes@cms.hhs.gov • Integrated Care Resource Center (TA contractor) www.integratedcareresourcecenter.com