Policy Academy Regional Meeting April 3, 2012

1. Financing and Sustainability: What Are Potential Sources of Public and Private Financing for Behavioral Health Evidence-Based Practices? Policy Academy Regional Meeting April 3, 2012

2. Session Objectives • Learn about key strategies to sustain services after demonstration grants end; identify how State agencies foster sustainability. • Identify potential financing strategies –both public and private—that could be used by States to support behavioral health evidence–based practices for older adults. • Learn aboutthe future direction of Medicare / Medicaid and how programming, the parity law, and the Affordable Care Act will affect seniors and senior behavioral health programming.

3. Financing and SustainabilitySession Outline Strategies for Sustaining and Financing Practices Today Alixe McNeill, MPA, National Council on Aging; Lessons Learned on Sustainability and Financial Resources Public Financing Mechanisms Nancy Wilson, MA, MSW, Baylor College of Medicine Washington State Medicaid Program and TX STAR+PLUS Medicaid Managed Care Mich Magness, Oklahoma Department of Mental Health & Substance Abuse Services, SAMHSA TCE Grant Funded Case Management to be Financed by Medicaid Private Financing Opportunities Tom Krajewski, MD, Integra Health Management Changing Health Care Environment: Opportunities in Medicare, Medicaid in the Affordable Care Act Michael Duffy, RN, BSN, SAMHSA Regional Administrator

4. Resource: Sustainability and Financing www.ncoa.org

5. Sustainability Framework

6. Program Impact and Fit • Demonstrated effectiveness • Designed for results • Fit with organizational mission • Readily perceived benefits • Financial resources & financing strategy • Articulated theory of change • Flexibility • Human resources

7. Organizational Capacity • Program champions / Leadership by CEO • Managerial and systems support • Integration in the organization • Organization stability and flexibility • Sustainability plan and action

8. Community Support • Community / state support of the programs • Availability of resources • Political legitimacy

9. Findings….Plan for sustainability EARLY...

10. Key Findings • Embedding services into ongoing systems useful • Example: depression care embedded to enhance case management • No one funding source was sufficient for sustaining services • Braided funding important • Sources varied: medical, mental health, aging • Services sustained were often billable including: • care management, depression care management, psychotherapy and psychiatry

11. Plan for Sustainability • Plan with partners • Embed in routine services • Identify what needs to be sustained (is it full program /practice or parts?) • Know costs • Investigate various public and private financial sources

12. Financial Resource Guide Basics on grants and other financing sources • Private Pay and Insurance • CMS • Medicare Fee for Service, Medicare Advantage • Medicaid State Plan Services, HCBS Waiver • SAMHSA • Uniform Block Grant for mental health & substance abuse • Screening, Brief Intervention, Referral to Treatment (SBIRT) • Primary and Behavioral Health Integration Grants • Mental Health Transformation

13. Financial Resource Guide • AoA - Older Americans Act • III-B State & Community Programs (care management, services) • III -D Disease Prevention/Health Promotion Services • III-E Family Caregiver • IV Research, Training & Development: (Discretionary) Evidence-Based Disease & Disability Prevention Program • FY-2012 Congressional appropriations NOW requires OAA Title IIID funding be used only for programs and activities which have been demonstrated to be evidence-based. For more information on the new requirement, visit AoA's Title IIID webpage.  

14. Financial Resource Guide • Additional Federal • CDC Research & Prevention • HRSA Federally Qualified Health Centers • USDA • State and Local Government • Special taxes • Philanthropic • Foundations • United Way • Partnerships • In-kind resources • Social enterprise

15. State Medicaid Financing of Evidence-Based Programsfor Older Adults Nancy L. Wilson Baylor College of Medicine Houston Center of Excellence in Health Services Research

16. Washington State • Medicaid State Plan: • Coverage for Major Depression Only • Medicaid HCBS 1915-c Waiver • Prevalence of depressive symptoms-LTC:60% • Gap in Service for 1/3 of clients • Client Training Service: skills to address minor depression • PEARLS (Program to Encourage Active and Rewarding Lives) EBP for Depression Care Management

17. PEARLS Program and Medicaid Delivery • PEARLS: RCTs established evidence for older adults and all-age adults with epilepsy • Univ. of Washington Health Promotion & King County AAA • Delivered in-home, 6-8 sessions, trained counselors, supervision by psychiatry • Waiver unit cost based on pilot by King County AAA • Infrastructure needed/cost included: screening, supervision, travel • Population density supports economic model

18. Texas: Behavioral Health Pilot for Adults:Money Follows the Person • Target population: Nursing home residents ≥ 3 mos. w/SMI Diagnosis or BH diagnosis with functional impairment (originally ≤ 65-now 12% 65+) • Partnerships for Finance and Delivery • MFP: Enhanced Medicaid match & flexibility • State DADS: Relocation Specialists • Medicaid Managed Care: HCBS and medical plans • State MH : contracts with local authorities • EBP: Cognitive Adaptive Training & Substance Abuse • Offered 6 mos. ≤ Before & up to 1 year after entry to community

19. Lessons & Options for Expansion and Scaling • Examples illustrate integration of mental health and substance use treatment services with HCBS • Recovery and cost outcomes encouraging: • 87% in comm., cost less than NH care, 33% SA use • Independent Evaluation: consider incorporation into HCBS waivers. Use new federal options to prevent institutional care- • Washington State: Included other waivered services to address psychosocial needs using client/caregiver training for persons w/Alzheimer’s Disease/dementia (EBP) • “Memory Care & Wellness Service”

20. For Further Information • Depression Care Management through PEARLS and Washington State 1915-C Medicaid Waiver • PEARLS website: www.pearlsprogram.org/ • Washington Medicaid (1915-c Waiver): http://www.nashp.org/webinars/supporting-behavioral-health/lib/playback.html •  Texas Behavioral Health Pilot • Upcoming Article: Spring 2012 Generations: Stoner & Gold • Dena.stoner@dshs.state.tx.us • Cognitive Adaptation Training: Velligan,D, Ritch and Maples, UTHSC-San Antonio

21. Outcome-based Financing Strategies Thomas Krajewski, M.D. Medical Director Integra

22. Public-sector Traditional Models Private Sector Fee-based Provider driven Service model Grant based Provider/advocacy driven Case model

23. Government Versus Private Sector Private =Profit -------------- Government =Politics The elephant in the room

24. Outcome Model Will work in either system Based on specific measurable goals/outcomes Outcomes related to quality and output Financing is based on success rate

25. Step 1-Identify Your Outcome

26. Quality Example

27. Step 2-Describe Your Intervention Keep it simple and clear Highlight any significant innovation Make sure the intervention can produce the outcome

28. How the Program Works • Locate, engage most challenging, highest need members • Meet onsite with participants, families, friends and evaluate needs • Identify, address issues driving avoidable ED, IP utilization • Develop individualized intervention plans • Arrange for, coordinate community-based services • OP, IOP, in-home • Social, housing services • Accompany, provide transport if needed (OP, pharmacy) • 24/7 accessibility -crisis contacts/interventions • Track admissions and facilitate timely, effective IP discharge planning

29. Why it Works • Local presence – collaborate with members, families, providers • Find & engage challenging members • 24/7 crisis stabilization to avoid unnecessary ER, IP admissions • Tie compensation to specific, measurable results • Ambulatory Follow Up after hospitalization • Admissions/readmissions • Projected claim costs • Seasoned team • Comfortable working with complex, challenging populations • UM/CM/DM experience • Integrated physical/behavioral health orientation

30. Step 3-Collect Your Data Begin on day one Make sure the data is relevant to the outcome Follow the data pattern regularly Make adjustments to the program as needed Finalize the results to prove your project’s success

31. Publicize Your Results Be Picturesque The important/funding people tend to have limited time available

32. Program Impact: (SMI) PROGRAM COHORT: IP ADMISSIONS (1/1 – 5/21)

33. Program Impact: (SMI) IP DAYS JAN ‘09 – NOV ‘10 (Pre/Post-Program) Inpatient Days Pre-Post Program

34. Funding Strategies Claims based (traditional fee-for-service) Case-based (episode of care or timeframe, i.e. monthly) Outcome-based (set targets) Risk-based (capitated per member per month) Gain-share (share savings with funder)

35. How It Works • Replaces fee-for-service with monthly case rate • Guarantees savings pay for case rate • Additional Gain Share - Shared savings with funder (75% to funder, 25% to Integra Health Management) • Shared savings predicated on achieving targeted outcomes • Incorporates risk (guarantee), gain share, case rate and outcomes-based funding strategy

36. Applicability • Medical Homes – • Add a nurse case manager to the team • Add the formalized inter-provider collaboration into the database • Add additional medical model training and health alert reporting • Accountable Care Organizations – manages the risk of high cost populations • Medical cost savings unknown at this time