Behavioral health payment improvement overview October 18, 2012 – Commission Meeting

1. DRAFT Behavioral health payment improvement overview October 18, 2012 – Commission Meeting PRELIMINARY WORKING DRAFT, SUBJECT TO CHANGE

2. Behavioral health levels of service Acute Inpatient Residential or Intensive Home & Community Based Intensive Outpatient Outpatient Early Intervention PRELIMINARY Recovery / Resilience Prevention Intensive Care Coordination Care Coordination Crisis Services Community-based options Screening and Assessment(e.g., level of care or service array determination for functional needs) SOURCE: Division of Behavioral Health Services

3. Key questions for identifying and prioritizing payment improvement initiatives A B C For today's discussion PRELIMINARY What are the key issues in the behavioral health system? Which of these issues can be addressed through payment? What is the prioritization of the payment initiatives? Which can be addressed through practice or policy changes?

4. Issues within the behavioral health system fall in 5 categories A PRELIMINARY Prevention Treatment Screening and assessment Recovery/ Resilience Early intervention

5. Issues in prevention PRELIMINARY Awareness of available services can be improved • Discrimination and stigma associated with behavioral health creates challenges for clients • Need to improve public communications around the services that are available Gaps in services for behavioral health needs (mental health and substance abuse) • Lack of funding for comprehensive array of prevention programs and support services • Need to provide options for behavioral health prevention in different settings (e.g., shelters, hospitals, long term care settings, schools, job centers, justice system, DHS) • Includes RSPMI, PBIS, PBSS, Coordinated School Health Services, anti-bullying • Limited utilization of peer, family / significant others, and community involvement services and supports for prevention • Need to improve identification of high risk populations, including those with BH needs among clients with physical or developmental disabilities Need for additional training programs • Prevention services need to be client centered • Lack of prevention training across key stakeholders, e.g., BH and DD providers, general practitioners, hospitals, job centers, shelters, teachers and other direct care staff Prevention

6. Issues in early intervention PRELIMINARY Gaps in early intervention services, including crisis intervention • Access to crisis intervention and stabilization services is limited, especially after-hours and on weekends • Lack of mobile crises services across the state • Additional early intervention tools can potentially be incorporated (e.g., SBIRT, Ages and Stages, Conscious Discipline, ACT teams) Existing early intervention can be enhanced • Limited consistency in early intervention across the state, e.g., EPSDT, juvenile drug and mental health courts, diversion, infant mental health, ACT teams • Lack of coordination with primary care providers and other direct care providers Areas for improvement in current referral and awareness programs • Education about referral options could be better coordinated by early intervention providers • Limited utilization of peer and family / guardian supports, including family / significant other education • There are gaps in significant others / family / guardian-oriented early intervention services Early intervention

7. Issues in treatment PRELIMINARY Gaps in current treatment delivery system • Need to develop the recommendation to create the Center of Excellence program to ensure centralized access to training resources for serving special populations • Individuals do not always have access to appropriate types of care (e.g., telemedicine, intensive outpatient, transportation) due to limitations in current set of offerings and workforce challenges, resulting in increased utilization of high intensity services • Lack of integrated mental health and substance abuse treatment Treatment is not always delivered in an evidence-informed manner • Treatment for some conditions across the state does not always accord with clinical practice guidelines (includes polypharmacy use) • The use of paraprofessionals is not always aligned with the level of care need • Unspecified diagnoses are used too frequently and for too long • Evidence-based standards (e.g., patient- and family-centered, trauma informed, gender sensitive, culturally informed, age appropriate) are not widely practiced • Client engagement in plan development and treatment is difficult and inconsistent • Standards for single point of entry providers need development and monitoring Care integration and coordination is limited • Some clients have multiple, separate behavioral health treatment plans, and treatment plans in multiple areas (e.g, BH with DD and LTSS) • BH care is not well coordinated with other care types and systems (e.g., primary, DD, LTSS) • Includes poor coordination of treatment throughout the continuum of care • Extends to gaps in pharmacy (e.g., medication management, polypharmacy) • Covers data and information sharing between providers • Substance abuse treatment is not integrated with mental healthcare Outcomes are not tracked effectively • Data and findings are currently not tracked and used effectively to inform program design and practice • Lack of integrated system for data transfer between providers / state agencies • Low participation rates in the YOQ Treatment

8. Issues in recovery and resilience PRELIMINARY There are gaps in the ways providers address recovery and resilience today • Clients do not always have clinical support after they leave high intensity levels of service (including community-based supports such as a 1915i, and case management/care coordination) • Limited support for clients in finding/maintaining housing and supportive employment • There is lack of funding for evidence-based recovery services Opportunity to improve consistency in existing recovery / resilience efforts • Providers and individuals may not always have a recovery-based orientation • Medical care for patients in recovery is often high cost and is not always well managed Consumer, peer, family, and community supports are not always leveraged most effectively • There is a lack of peer support in recovery • Limited structure for engaging and communicating with consumers in recovery Recovery / Resilience

9. Issues in screenings and assessments PRELIMINARY Inconsistent screening and assessment process • Medical providers may not routinely screen for behavioral health issues (e.g., children during Well Child checkups and post-partum depression screenings) • There are inconsistent evaluations of need for determining the most appropriate level of care • Need to ensure that people get the right screenings irrespective of where they enter the system • Screening and assessment process is not coordinated, meaning some clients receive redundant assessments • Training on administering assessments can be improved to ensure results accurately reflect client circumstances Need to improve the use of data • Can improve collection of information from multiple sources (including other departments) • Can increase availability of data to providers and stakeholders • Support providers in accessing information through electronic systems Arkansas has a high prevalence of SED/SMI designations • There may be premature diagnoses of severe mental health conditions, resulting in some over-identification • Definitions need to be enhanced to include functional needs Screening and Assessments

10. Incentive The goal How it works B The Arkansas approach is designed to reward coordinated, team-based care across the whole person and for specific conditions or procedures How we are implementing it… Medical homes andHealth homes Episode-based care delivery Our overall approach • Providers proactively work as a team to manage a client’s overall health • Client journey: all healthcare and support services needed by a client over time • Client journey: all services related to a specific condition, procedure, or physical / developmental disability • Typically one provider is designated as ‘quarterback’ for all client needs for a period of time • Quarterback: the provider in best position to influence prevention and management of chronic disease • Quarterback: ‘Principal Accountable Provider’ in best position to influence cost and quality of services for the episode • Providers are rewarded for providing high-quality care at an appropriate cost • Outcome measured includes overall health of the provider’s client population (across all conditions and episodes) • Outcome measured is average cost and quality of care for all clients that experience a given ‘episode’ (e.g., a surgery)

11. Comprehensive Assessment Referral Referral Referral Acute inpatient Residential or Intensive Home and Community Based (includes CFCO) Intensive Outpatient (May include 1915i) Behavioral Health: innovative care delivery system PRELIMINARY DRAFT: SUBJECT TO CHANGE Example providers • Rehabilitative service provider • CMHC • LMHP • Primary care providers • AHEC • Substance abuse providers • School-based mental health • Other community supports Care coordination by PCMH Recovery Outpatient Example providers • CMHC • LMHP • Primary care providers • AHEC • Substance abuse providers • School-based mental health Care coordination by PCMH Recovery Prevention Screening and Initial Assessment Outpatient Intensive care coordination by Health Home Early Intervention Example providers • Rehabilitative service provider • CMHC • LMHP • Primary care providers • Psychiatric hospital • Acute care facility • Private residential treatment facility • Substance abuse providers Recovery

12. Behavioral health reform options 1915(i) CFCO Regular FMAP 6% FMAP increase Eligibility criteria does not require institutional level of care determination Eligibility criteria requires institutional level of care determination Benefits can be targeted to a specific population ("Targeted benefits"), services can differ in amount, duration, and scope Services must be provided without regard to the individual’s age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports the individual requires to lead an independent life Both options provide community and home based services and supports

13. Potential payment initiatives to address issues within the BH system 1 Health homes (& link to medical homes) • Deliver integrated care coordination to facilitate quality care and positive outcomes through: • Ensuring effective treatment of BH conditions • Integrating care coordination across BH, medical, and long-term supports 2 Episode-based care delivery • Increase adoption of evidence-informed practices by creating accountability for all services related to a specific BH condition (e.g., ADHD, and potentially ODD, depression and bipolar disorder) 3 Reimbursement adjustments • Modify reimbursement rules to encourage appropriate diagnosis and utilization of services (e.g., placing appropriate time limits on unspecified diagnoses) B 4 Reimbursement for new services • Add reimbursement for selected new services that are known to be cost-effective and evidence-informed (e.g., crisis intervention, substance abuse treatment services, medication management, rural access and community-based services) 5 Reimbursement for pharmacy (including polypharmacy) • Build on recent work in pharmacy management utilization rules to ensure appropriate use of medications (includes polypharmacy, therapy interactions, step therapy, and dosage) 6 Policy changes/enabling initiatives • Develop policy changes or initiatives that enable or compliment the payment initiatives (e.g., changes to certifications for all BH providers, specialty certifications, new screenings) PRELIMINARY Initiative Description

14. Appendix – Acronym dictionary • AHEC Area Health Education Center • BH Behavioral health • CFCO Community First Choice Option • CMHC Community Mental Health Center • DD Developmental disabilities • EPSDT Early Periodic Screening, Diagnosis, and Treatment • LMHP Licensed Mental Health Provider • LTSS Long term services and supports • NCQA National Committee for Quality Assurance • PBIS Positive Behavioral Interventions and Supports • PBSS Positive Behavioral Support System • PCMH Patient Centered Medical Homes • RSPMI Rehabilitative Services for Persons with Mental Illness • SBIRT Screening, Brief Intervention, and Referral to Treatment • YOQ Youth Outcomes Questionnaire