Virginia Housing Alliance: Housing is Health - Supportive Housing for a Healthier Commonwealth

1. Housing, Medicaid and other fun topics!Virginia Housing Alliance: Housing is Health: Supportive Housing for a Healthier           CommonwealthJune 12, 2019

2. Behavioral health redesign

3. Why Redesign? Why Now? Medicaid is the largest payer of behavioral health services in Virginia 40th in the country for overall access to mental health care 41st in the country for mental health workforce supply $$$ 28% (mentalhealthamerica.net) of Medicaid members had either a primary or secondary behavioral health diagnoses

4. The Vision for Redesign Develop an evidence-based, trauma-informed, cost-effective continuum of care • Keep Virginians well and thriving in their communities • Improve behavioral health services and outcomes for members in current and expansion populations • Meet people’s needs in environments where they already seek support such as schools and physical health care settings • Invest in prevention and early intervention services that promote resiliency and buffer against the effects of adverse childhood experiences

5. STEP VA: A Foundation for Redesign STEP-VA has paved the way forward in creating a path for BH system change in the 21st century. Redesign of the Medicaid-funded system supports long term sustainability Strong Public Behavioral Health System

6. Alignment & Momentum for Redesign

7. Redesign Process and Progress • Development of Interagency Team • Consultation with Farley Health Policy Center and collaborative development of deliverables • Service Gap Analysis, Evidence Review, Stakeholder Survey, Continuum • Partnerships with Stakeholders and Initiation of Workgroup • Meetings 10/2, 10/23, 11/27; 1/7, 3/13

10. *services across all levels CURRENT SERVICES REDESIGNED SERVICES Universal Prevention/ Early Intervention Prevention • Early Intervention/Part C • Screening • EPSDT • Early Intervention Part C • EPSDT Services • Screening Across Lifespan • 0-5 Services/Home Visiting • Comprehensive Family Programs • Early Education Recovery & Rehabilitation Support Services Recovery • Peer and Family Support Partners • Independent Living and Recovery Services • Peer & Family Support Services • Psychosocial Rehabilitation (EBPs) • Permanent Supporting Housing • Supported Employment Outpatient Services Outpatient • Outpatient Psychotherapy • Psychiatric Medical Services • Integrated Physical and Behavioral Health • Tiered School-based Behavioral Health Services • Outpatient Psychotherapy • Psychiatric Medical Services Intensive Community-Based Support Community Mental Health & Rehabilitation Services • Intermediate/Ancillary Home-Based Services • MST, FFT, High Fidelity Wraparound • Intensive Community Treatment • Assertive Community Treatment • Therapeutic Day Treatment • Mental Health Skill Building Services • Psychosocial Rehabilitation • Intensive In-home Services • Partial Hospitalization/Day Treatment • Mental Health Case Management* • Treatment Foster Care Case Management* • Behavioral Therapy* • Intensive Community Treatment • Crisis Intervention & Stabilization Intensive Clinic/Facility Based • Intensive Outpatient Programs • Partial Hospitalization Programs Comprehensive Crisis • Mobile Crisis, Peer Crisis Support • Crisis Intervention • Crisis Stabilization Residential/Inpatient Residential/Inpatient • Therapeutic Group Home • Psychiatric Residential Treatment Facilities • Inpatient Psychiatric Treatment • Therapeutic Group Home • Psychiatric Residential Treatment Facilities • Inpatient Psychiatric Treatment

11. Changes in New Continuum Key Overall Changes • System will increase focus on prevention and early intervention services and principles of trauma-informed care • Case management and evidence-based behavioral therapies will be available across all levels of care • Outpatient behavioral health services will be more robust and integrated into schools and primary care • Community Mental Health and Rehabilitation Services will become Intensive Community-Based Supports that are tiered based on the intensity of an individual’s needs and include evidence-based best practices • Medicaid will fully fund comprehensive crisis services • System will promote telemental health across levels of care

12. Implementation Planning

13. Implementation Planning WORKFORCE

14. Proposed Phased Implementation Timeline Behavioral Therapy Home Visitation Comprehensive Family Programs High Fidelity Wraparound Case Management

15. Phase 1 – Summer 2020 • High intensity services for both adult and child • Services that have an short/medium term impact on the State Psychiatric Facilities census • Considers services with existing framework that can be expanded in scope, workforce, or contribute to sustainability. For example: • PHP and IOP network and rates may model ARTS • PACT is not at every CSB and not fully covered by DMAS • MST and FFT providers: • Have been trained however only accessible for DJJ / CSA referral • Have been identified by the FFPSA team as an EBP • Considers including services that align with STEP-VA initiatives (outpatient, crisis services) Partial Hospitalization Program Intensive Outpatient Program Program of Assertive Community Treatment Comprehensive Crisis Services Multisystemic Therapy Functional Family Therapy

16. The Future for the Commonwealth: A comprehensive spectrum of behavioral health services • Bring the Commonwealth into the Top 10 in national rankings for behavioral health outcomes • Shift from working with a reactive, crisis-driven, high-cost system reliant on intensive services to one that is proactive/preventive, cost-efficient, and focused on providing services in the least restrictive environments • Build upon existing statewide behavioral health transformative initiatives and create sustainability and expansion for evidence based services • Integration of trauma-informed care principles across the continuum to empower individuals to build resiliency and overcome the impact of adverse experiences so that they can lead meaningful, productive lives in our communities • Build a robust children’s behavioral health system to address prevention and early intervention of mental health problems to allow each child the chance to reach their full developmental potential

17. Medicaid Expansion and the COMPASS waiver

18. “Creating Opportunities for Medicaid Participants to Achieve Self-Sufficiency” (COMPASS) Waiver On June 7, 2018, Governor Northam signed the 2018 Virginia Acts of Assembly Chapter 2 (2018 Appropriations Act), which authorized Medicaid expansion and required changes to the Medicaid Program. Work and Community Engagement Requirements Premiums, Co-payments, Health and Wellness Accounts Housing and Employment Supports Benefit for High Needs 18

19. Overview of the COMPASS Waiver Components Section 1115 Demonstration Waiver Components Work/Community Engagement (TEEOP) • Requirement to participate in training, education, employment and other community engagement opportunities for up to 80 hours per month in order to maintain Medicaid coverage. • Applies to all “able-bodied adults” in the Medicaid program who do not meet an exemption (e.g., parents of dependent children, medically-frail, disabled). Health & Wellness Program • Requirement for premiums and co-payments, health & wellness accounts and healthy behavior incentives. • Applies to Medicaid enrollees with incomes between 100-138% FPL, who do not meet an exemption. Exemptions are the same as in the TEEOP program. Housing & Employment Supports for High-Risk Enrollees • A supportive housing and employment benefit for high-risk Medicaid enrollees, including those with severe mental illness, substance use disorder, or other complex, chronic conditions.

20. COMPASS 1115 Waiver Process Overview November 20, 2018 January 6, 2019 – Present and Ongoing September 20, 2018 – October 20, 2018 December 7, 2018 – January 6, 2019 DMAS is currently negotiating the COMPASS waiver features with the federal government. The federal government released the COMPASS waiver for the federal public comment period. DMAS released the COMPASS waiver for public notice. Over 1,800 public comments were received. DMAS submitted the COMPASS waiver to the federal government.

21. Background on Section §1115 Federal Authority • Under Section 1115 of the federal Social Security Act, the Secretary of Health and Human Services has authority to approve a state’s requests to waive certain provisions of federal Medicaid law. • An 1115 Waiver must be: • An experimental, pilot or demonstration project; • Likely to assist in promoting the objectives of the Medicaid program; • Budget neutral to the federal government; and • Limited in duration to the extent and period necessary to carry out the demonstration. • States must provide a public process for notice and comment on proposed demonstration applications and extensions. Source: Social Security Act (SSA) § 1115. 21

22. Housing and Employment Supports for High-Need Enrollees The Commonwealth will provide certain eligible, high-need Medicaid enrollees, including those with severe mental illness, substance use disorder, or other complex, chronic conditions, supports necessary to obtain and maintain employment and stable housing, thereby improving enrollees’ quality of life and health outcomes. Employment Supports Housing Supports Virginia will offer 1915(i) services to Medicaid enrollees ages 18 or older who meet the certain needs-based criteria and risk factors that would otherwise be allowable under a 1915(i) Home & Community Based Services (HCBS) State Plan Amendment (SPA) Habilitation services that help individuals gain access to and sustaining employment • Case Management • Educational Services • Pre-Vocational Services • Supported Employment Services (individual and small group) HCBS services that support individuals in securing and sustaining housing • Individual Housing Transition Services, including Community Transition Services • Individual Housing and Tenancy Sustaining Services Housing and employment supports include benefits that are otherwise be allowable under a 1915(i) Home & Community Based Services (HCBS) State Plan Amendment (SPA). The related needs based criteria and risk factors are detailed in the COMPASS Waiver Application on pages 14-18, on the DMAS Website at: http://www.dmas.virginia.gov/#/1115waiver

23. CMS Negotiations: Status Update and Next Steps DMAS has simultaneously been working with sister agencies to plan for operationalization of the waiver programs.