Behavioral Health Care Coordination
Behavioral Health Care CoordinationRe-opening of enrollment webinarJanuary 15, 2019
Introduction to today’s webinar Ohio Medicaid and Ohio Mental Health and Addiction Services have beenworking closely with a group of clinicians and the Medicaid managed care plansto develop an innovative behavioral health care coordination (BHCC) programdesigned to meet the needs of Medicaid members with severe behavioral healthconditions Service start for the BHCC program will begin on July 1st, 2019 The first round of enrollment occurred in July 2018. After some of you expressedinterest in joining the BHCC program, we have decided to re-open enrollmentfrom January 21st to February 1st for participation in July 1st service start We’re excited about the opportunity to improve care for eligible members andto deepen support to qualified behavioral health entities (QBHEs) participatingin the program The purpose of today’s session is to share information about the program designand discuss the application process2
Provider webinar agendaOverview of the BHCC program andmember/provider benefitsBHCC implementation plan and progressBHCC program designReportingApplying to the BHCC program and next stepsQ&A3
Reminder: Behavioral Health Redesign Strategic Plan1. Elevation (2012) – shift Medicaid match to the state to ensure moreconsistent provision of treatment services statewide, supported byDepartments of Medicaid and Mental Health and Addiction Services2. Expansion (2014) – extended Medicaid coverage to more than630,000 very low-income Ohioans with behavioral health needs whopreviously relied on county-funded services or went untreated3. Modernization (January 1, 2018) – expand Medicaid services forindividuals with the most intense need and update Medicaid billingcodes for behavioral health providers to align with national standards4. Integration (July 1, 2018) – coordinate physical and behavioral healthcare services within Medicaid managed care to support recovery forindividuals with a substance use disorder or mental illness4
Our goal is to fulfill BH redesign and create a coordinated BH caresystem Require health plans todelegate components ofcare coordination toqualified behavioral healthcenters (“Model 2”commitment) Care managementidentification strategy forhigh risk populationMedicaid ManagedCare PlanQualified BehavioralHealth Center Require health plans tofinancially reward practicesthat keep people well andhold down total cost ofcare, including behavioralhealth Care coordination defaultsto primary care unlessotherwise assigned by theplanComprehensivePrimary Care (CPC) Mutual Accountability Alignment on care plan, memberrelationship, transitions of care, etc. Common identification of needs andassignment of care coordination5
How will care coordination change?How can the State, MCPs and providers bestsupport members with behavioral health needs?Total Medicaid of members withBH needs are beingappropriatelymanaged throughprimary care2.8Mz30%Currently receive more intensivesupport or are eligible for additionalservices under BH Redesign25-10% of the BHpopulation require intensivecare coordination1 Members who have been diagnosed with and treated for a behavioral health condition2 “Currently receiving intensive support” is defined as those currently in health homes or receiving TCM, but not those receiving CPST;“Eligible for additional services under BH redesign” includes those eligible for ACT and IHBT, but not SRS6
Overview of BH Care Coordination programMembersmatched withQualifiedBehavioral HealthEntities (QBHEs)Qualified BH Entities form a care team, supporting the members andbeing held accountable both behavioral and physical health ionhealthmanagementCare agement &relationshipEngagingsupportiveserviceAccessto careTransitionof care7
Benefits of BH Care Coordination for membersRelationship with the provider best equippedto serve member needs through advancedmember-provider matchingAssistance with fighting substance usedisorder through increased communicationand collaboration with recovery servicesMore integration between physical andbehavioral health care providers through newtools to facilitate data sharing and increasedpresence of care coordinatorsEnhanced chronic condition managementthrough care coordinators and expanded roleof provider in developing comprehensive careplansSupport for member choice through memberfocused care modelEnhanced access to specialty providers byreducing barriers to scheduling appointmentsReduced inpatient and ED admission frequencythrough greater utilization of preventativehealth programs such as depression screeningImproved treatment adherence throughmeasurement of treatment adherence andincreased member follow-upFewer disruptions to care through increasedcollaboration between PCP/ CPC/MCP/QBHEbefore and after transitions to care8
BHCC program benefits - providers Improve access by connecting more members to qualifiedbehavioral health entities (QBHEs) to provide care coordination Create a more flexible payment structure, shifting away from15 min FFS payments to a single monthly rate Reward high performing providers through connections withnew members and a bonus payment Increase data sharing to aid QBHEs in better serving theirmembers Improve care through better integration of primary care andbehavioral health care Strengthen coordination and best practice sharing amongentities, plans, and the State through regular touchpoints9
Provider webinar agendaOverview of the BHCC program andmember/provider benefitsBHCC implementation plan and progressBHCC program designReportingApplying to the BHCC program and next stepsQ&A10
Implementation plan for July 1, 2019service start2018ActivityCurrent dateJulOctJanAprOct2020JanJulFile rule Rule approved Rule effectiveSPA and pre-print approved(latest timeframe)Draft SPA & pre-printProvider readinessMCP and responsibilitiesConduct final analysis for budgetimplicationsRe-open enrollmentNotify Jan-applied providers of enrollmentNotify Jul-appliedproviders of enrollmentRun providerenrollmentEducate providersUpdate provider agreementAmend provider agreementContractingAdditional time to contract withJanuary applied providersMCPs update QBHEcontractsCreate review toolPlan readinessConfigure systems for paymentConductreviewFinal readiness review completeBuild systems and reportsAttribution andreportingAttributionestimates rtrefreshBHCC services deliveredPaymentMonthly activity payment for BHCC servicesPerformance periodfor bonus payment beginsPerformance period for September 2020 bonus payment11
Progress made to gPlan readinessAttribution andreportingPaymentState responsibilitiesMCP and sharedresponsibilities Rule effective as of January 10th, 2019Have been meeting with SAMHSA and CMS to discuss the BHCC program and finalizing draftsof SPA and pre-print for submission to CMS Incorporating BHCC program into ODM budget narrative 82 providers applied July 2018 for participation in the BHCC program. These providers will benotified of their enrollment status by January 18thEnrollment is re-opening January 21st-February 1st, with a webinar on January 15thMeeting with providers who applied in July 2018 to discuss workplan, program design, andhow to read reports that are being released Provider agreement is updated to reflect the BHCC programMCPs will begin contracting with providers who applied July 2018 and are accepted into program Plans configuring their systems per provided BHCC program specifications Initial reports being shared with providers who applied for the program in July 2018. Thesereports will be refreshed on a quarterly basisProviders who apply in the re-opened enrollment period will receive their reports in Juneahead of July service start Designed monthly activity payment and bonus payment methodology12
Provider webinar agendaOverview of the BHCC program andmember/provider benefitsBHCC implementation plan and progressBHCC program designReportingApplying to the BHCC program and next stepsQ&A13
BHCC program designProvider requirementsTarget populationAttributionPayment14
PROVIDER REQUIREMENTSProvider requirementsTextInitial eligibility requirements Entities must meet 100% of requirements Re-assessed during annual enrollment periodTextActivity requirements Entities must meet 100% of requirements Assessed annually for each providerTextPerformance requirements Entities must meet 50% of quality and 50% of efficiency requirements Reports released quarterly; performance evaluated annually. Data publishedon a six month lag15
PROVIDER REQUIREMENTSInitial eligibility requirements (1/2)ProvidereligibilityProvider must: Satisfy certification requirements set forth in paragraph (A)(1) of rule 5160-27-01 of theAdministrative Code and in calendar year 2017 or later have provided both mental health (type84) and substance use disorder (type 95) treatment services Or meet the requirements stated in (G)(2)(a) of rule 5160-2-75 of the Administrative Code if anoutpatient hospital provider One individual who serves as key point of contact for MCPs/State to discuss performance Identification of a care team, including the following roles:– Case manager to lead care coordination relationship, serving as primary point of contact forPersonnel member and family– Registered Nurse(s) or licensed practical nurse to consult and coordinate with member’s othermedical providers– Program administrative contact to act as the single point of contact to fulfill records requestsand perform other administrative activitiesAt the time of submitting an enrollment application to become a QBHE, have at least onepractitioner from each of the following categories affiliated with the entity:– A practitioner with prescribing authority in the state of Ohio;– A registered nurse or licensed practical nurse; and– An other licensed professional as described in rule 5160-8-05 of the Administrative CodeSpecific staffing ratios will not be mandated, but a recommended range can be given to providers16
PROVIDER REQUIREMENTSInitial eligibility requirements (2/2)ToolsQBHEs will have the ability to: Share, receive, and use electronic data from a variety of sources with other health care providers,ODM, and the MCPs; Use consent forms containing elements necessary to support the full exchange of healthinformation in compliance with all applicable state and federal laws Submit prescriptions electronically Implement and actively use an electronic health record (EHR) in clinical services Send, receive, and use continuity of care records through the use of standard electronic formatssuch as FHIR and C-CDA– If QBHE enrolled in the BHCC program prior to July 1, 2019, QBHE will be prepared within sixmonths of July 1, 2019 service start (January 2020)– If QBHE enrolled in the BHCC program after July 1, 2019, QBHE will be prepared at the timeof applicationCommitment tointegrationEntity meets one of the following requirements: Have an ownership or membership interest in a primary care organization where primary careservices are fully integrated and embedded; Enter into a written integrated care agreement such as a contract or memorandum ofunderstanding with a primary care provider; or Achieve implementation of primary physical health care standards by a national accrediting entityas an integrated primary care-behavioral health provider, primary care medical home orbehavioral health home17
PROVIDER REQUIREMENTSActivity requirements of QBHEs and corresponding G-codesG9004: Lead initial outreach andengagement, including performinginitial outreach to the member andbuilding a trust-based relationshipG9012: Conduct populationhealth management,including the continuousidentification of highest riskmembers and alignmentwithin organization to focusresources and interventionsInitial outreach/EngagementPopulation healthmanagementG9011: Engage supportiveservices, including facilitatingaccess to communitysupports and communicatingmember needs to communitypartnersG9010: Engagement with andaccess to appropriate care,including support forscheduling and engagingdirectly with the member’sother providersEngagingsupportiveserviceAccess tocareCare planG9005: Develop care plan, includingleading development of theintegrated care plan by gatheringinput from the member, otherproviders, and the member’s socialsupport systemOngoingengagement &relationshipG9006: Lead ongoing relationshipand engagement, including regularcheck-ins with the member tosupport treatment adherence, andhigh-touch support in crisissituationsTransition of careG9007: Ease transitions of care,including monitoring andcommunicating about transitionneeds18
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Outreach and engagementQBHEs support members through care coordinationactivitiesInitial outreach/EngagementPopulation healthmanagementRole of QBHEsRole of MCPsCollaborating withCPCs/PCPs Careplan Ongoingengagement &relationshipEngagingsupportiveserviceAccess tocareLeads initial memberoutreach, includingeducation on programbenefits and necessaryenrollment activitiesLeads initial outreach withmember’s CPC/PCP to shareinformation regardingprogram participation andcare plan developmentBuilds trust-basedrelationship to understandmember’s preferences andgoals and begins engagingwith family or socialsupport system (e.g.,schools, youth services)As needed,provides data toBH entity toassist withidentification ofhighest riskmembers,including timelyupdatesregarding patientutilization ofbehavioral andphysical healthservices Shares physicalhealthinformationrelevant toprogramparticipation anddevelopment ofthe care planMay identifymembers whomeet the claimsbased definitionfor programparticipatingTransition of care1 Additional discussion required for responsibility in Q119
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Care planQBHEs support members through care coordinationactivitiesRole of QBHEsRole of MCPsCollaborating withCPCs/PCPs Initial outreach/Engagement Population healthmanagementCareplanLeads creation andmaintenance of integratedcare plan, including leadingoutreach to CPC/PCP toincorporate inputs forphysical health sectionDevelops specific inputs forbehavioral health section ofcare planProvides input tocare plans asnecessaryProvides input tointegrated careplan bydevelopingsection formembers’ physicalhealth needsOngoingengagement &relationshipEngagingsupportiveserviceAccess tocareTransition of care20
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Ongoing engagement andrelationshipQBHEs support members through care coordinationactivitiesInitial outreach/EngagementPopulation healthmanagementRole of QBHEsRole of MCPsCollaborating withCPCs/PCPs Careplan Ongoingengagement &relationshipEngagingsupportiveserviceAccess tocareTransition of careServes as primary point ofcontact for membercommunication aboutbehavioral and physicalhealth needsLeads member and familyeducation on behavioralhealth, including self-careand adherence to treatmentplanLeads follow ups withmember on behavioralhealth care and updates thecare plan and CPC/PCP asappropriate Notifiesmembersregardingprogrameligibility asnecessaryEducatesmembers,families, andother socialsupports aboutthe program andbenefits ofprogramparticipation Educates memberand their familyon physical health,self-care, andtreatmentadherence, withunderstanding ofbehavioral healthconditionsProvidesinformation tomembers relatedto their physicalhealth needsLeads follow upswith member onphysical healthcare and updatesthe care plan andqualified BH entityas appropriate21
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Transition of careQBHEs support members through care coordination activitiesInitial outreach/EngagementPopulation healthmanagementRole of QBHEsRole of MCPsCollaborating withCPCs/PCPs Careplan Ongoingengagement &relationshipEngagingsupportiveservice Access tocareTransition ofcare Leads outreach to CPC/PCPafter major behavioral healthevents (e.g., inpatient stay)and discusses implications forphysical healthcareFollows up with CPC/PCPfollowing major physicalhealth related events anddiscusses implications forbehavioral health care as wellas transition needs (e.g.,transportation, medicationrestrictions)Establishes relationships withEDs and hospitals, andmonitors admissions anddischarges. Accountable forfocus on admissions anddischarges related tobehavioral health treatmentNotify the member’s MCP inthe event of a transition intoand out of SUD residential,ACT, and IHBT as potentiallyduplicative servicesIf needed, transitionsmember’s care plan to newQBHE Answers questionsrelated to eligiblebenefits to supporttransitions of care(e.g., questionsabout potentialproviders to referto)Coordinate withthe QBHE duringthe member’stransition into andout of SUDresidential, ACT,and IHBT toprevent theduplicative billingof servicesAssist themember, in theevent of need, tofind a new QBHEbased on memberpreference, visithistory, and geoproximity Leads outreach toqualified BH entityafter major physical health events(e.g., inpatient stay)and dis-cussesimplica-tions forbeha-vioralhealthcareFollows up withqualified BH entityfollowing majorbehavioral healthevents (e.g., inpatient stay) anddiscusses implications for physicalhealth careAccountable forfocus on admissionsand discharge forphysical healthrelated treatment22
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Engagement with and accessto appropriate careQBHEs support members through care coordination activitiesRole of QBHEsRole of MCPs Leads scheduling with guidance Addresses Initial outreach/EngagementPopulation healthmanagementCareplan Ongoingengagement &relationshipEngagingsupportiveserviceAccess tocareTransition of care from CPC/PCP, works withmember to reduce barriers toattendance for appointmentsLeads follow-ups with CPC/PCPto understand implications fromambulatory or acute encounters(e.g., treatment adherence)Engages directly with member’sphysical and other BH providersas well as community resourcesto support care, includingupdates to care planAccountable for referraldecision support and schedulingfor behavioral health care in IP,OP, and ED settingsStabilizes crises by gatheringinformation from member,CPC/PCP, social support system(e.g., schools, youth services),and other medical providersand formulates a response forimmediate intervention and/orstabilizationchallenges toappropriate accessto care, andescalates to Stateas appropriateCollaborating withCPCs/PCPs Provides primarycare Supports scheduling with guidance fromqualified BH entityand works withmember to reducebarriers toattendanceFollows up with BHcare coordinator tounderstandimplications forphysical health frombehavioral healthencounters (e.g.,medicationmanagement)Accountable forreferral decisionsupport andscheduling for PHcare in inpatient,outpatient, andemergency settings23
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Engage supportive servicesQBHEs support members through care coordinationactivitiesInitial outreach/EngagementPopulation healthmanagementRole of QBHEsRole of MCPsCollaborating withCPCs/PCPs Facilitates access tocommunity supports byworking with supportiveservices partners to addressmember needsAs iveservicesEngages withsupportiveservices asrequired tosupport physicalhealth careCareplanOngoingengagement &relationshipEngagingsupportiveserviceAccess tocareTransition of care24
PROVIDER REQUIREMENTSRole of QBHE, MCP, and CPC/PCP: Population healthmanagementQBHEs support memb
Primary Care (CPC) Qualified Behavioral Health Center Require health plans to . Draft SPA & pre-print Build systems and reports Conduct review Educate providers . Quarterly report refresh Quarterly report refresh File rule Attribution estimates shared Quarterly report refresh Quarterly report
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Measures outcome rather than care coordination actions Cost Measures Select utilization measures in alignment with model of care Measures may need to vary by practice and patient population Measures outcome rather than care coordination actions What accountability mechanisms exist to track the effectiveness of care coordination? 1.
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