Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States
Kristin Andrews, Jonathan D. Brown, Tara Ferragamo, Rebecca Kleinman, Rebecca Newsham, and Allison Wishon Siegwarth
Mathematica Policy Research
Individuals with serious mental illnesses and other chronic behavioral health conditions need access to a comprehensive array of physical health, behavioral health, and other supportive services. Yet few of these individuals receive this type of care. Recent research suggests that less than 5 percent of Medicaid beneficiaries with schizophrenia or bipolar disorder receive continuous medications, minimal medication monitoring, psychosocial services, and preventive physical health care (Brown et al. 2012).
Fragmentation in the financing and delivery of services leads to gaps in the quality of care. Some states, however, are implementing programs intended to better integrate and coordinate the delivery of comprehensive services for individuals with behavioral health conditions through a variety of financing mechanisms and delivery models. For instance, some states are integrating behavioral and physical health benefits into their Medicaid managed care contracts or are incorporating other supportive services or care coordination efforts into these arrangements (Greenberg 2012; Kim et al. 2012; Hamblin, Verdier, and Au 2011). Other states are adopting enhanced primary care case management (PCCM) programs that provide payments to providers and other incentives and tools to ensure that individuals receive comprehensive services. More information on how states are financing and organizing the delivery of services will help federal and state policymakers in their efforts to improve the integration and coordination of care.
Under contract to the Office of the Assistant Secretary for Planning and Evaluation, Mathematica Policy Research conducted case studies of four state programs in which different strategies are being used to improve the integration and coordination of care for adults with behavioral health conditions. Data for the studies came from an environmental scan and discussions with state officials and other stakeholders. The four study states and their programs are:
Louisiana: Several state agencies pool funding into a contract with one managed care organization (MCO) to manage the delivery of specialty mental health and substance abuse services for Medicaid and non-Medicaid populations.
North Carolina: Enhanced PCCM is used to coordinate services for Medicaid beneficiaries and to support primary care providers' (PCPs') ability to function as medical homes for individuals with behavioral health conditions.
Tennessee: All Medicaid MCOs are responsible for physical and behavioral health benefits, and the state has recently integrated long-term care services into its managed care contracts.
Vermont: As part of a statewide multipayer initiative, the state is working to transform primary care practices into patient-centered medical homes (PCMHs) that provide mental health services and support community health teams (CHTs).
As summarized in Table ES.1, these state programs harness different funding streams and use a variety of strategies to organize and deliver care. To some extent, each program reflects the unique state environment in which it was developed. As one program representative noted, there is not a one-size-fits-all approach to improving the integration and coordination of care. Some states tailored their programs to existing programs and infrastructure; others opted for wholesale system reform.
Despite these differences, some features are common to all four states. An important component of each program is to connect individuals with an array of state- and community-funded social services such as housing assistance and employment services. The use of information systems are critical components as well. Several programs are either providing an electronic health record (EHR) platform and/or encouraging providers to use EHRs and other information technologies, such as web portals and registries, to share patient information, coordinate care, and inform clinical decision-making. The states are also using information from these systems to monitor the quality of care. Finally, each program has employed a variety of quality-improvement strategies in order to help meet program goals.
The case studies are a useful snapshot of states' activities, but further research could focus on the implementation and effectiveness of specific program components; this information could help policymakers implement similar programs elsewhere in the nation. For instance, qualitative data could tell us more about the structures and processes of care in these four programs, and about the implementation successes and challenges. States are using claims data and EHRs to develop quality monitoring infrastructures, which could be used to examine the impact of these programs on service utilization and costs. Future evaluations of these programs must take into account the specific context in which they were implemented.
|TABLE ES.1. Summary of State Programs|
|Program name and start date||Louisiana Behavioral Health Partnership; March 1, 2012.||Community Care of North Carolina (CCNC); expanded statewide in 2001; behavioral health program implemented in 2010.||TennCare; 2007 (behavioral health services fully integrated by 2009).||Vermont Blueprint for Health; expanded statewide in 2010.|
|Program description||Manages statewide specialty mental health and substance abuse services through a single contract with Magellan Health Services.||Statewide population management and care coordination infrastructure founded on a PCMH model. The behavioral health program supports PCPs acting as a medical home for individuals with behavioral health conditions.||TennCare is the state Medicaid program. All managed care contracts integrate physical and behavioral health services.||Statewide, multipayer PCMH initiative to improve health care and population health while reducing costs.|
|Population covered||Medicaid adults (including dual eligibles) and non-Medicaid-eligible adults; specialized services for children/youth.||Medicaid adults (including dual eligibles).||Medicaid adults.||All patients are eligible for core PCMHservices.|
|Services covered||Inpatient psychiatric services, outpatient mental health services, rehabilitative substance abuse services, case conferencing services, crisis intervention, psychosocial rehabilitation, and other community psychiatric supports and treatment.||Care management and coordination between physical health, behavioral health, and social services, monitoring of adherence to medication regimen, assistance with care transitions and hospital discharge planning.||Primary care, behavioral health, substance abuse services, long-term care, home and community-based services, housing and employment-support services.||Case management and care coordination, treatment of behavioral health conditions in primary care, coordinated treatment for opioid addiction through the Hub and Spoke model, outreach on preventive screenings, and self-management and behavior modification through workshops.|
|Mechanism(s) for coordinating physical and behavioral health services||A toll-free, 24-hour-a-day number allows individuals to talk with a care manager. Independent assessment conducted for some consumers to develop care plans. Case managers from Magellan and physical health plans share information.||Medicaid beneficiaries must choose a PCP. Care managers work with patients to ensure they receive health care, medications and support services.||TennCare members are matched with a primary care physician. MCOs rely on providers' assessments of patients' need for case management.||Supports locally developed multidisciplinary CHTs to support PCMHs, provide case management and care coordination, patient workshops, quality payments to providers, and health information technology.|
|Funding sources||Funding is pooled from several state agencies into the contract with Magellan. The program operates under a 1915(b) waiver, a 1915(c) home and community-based waiver, and 1915(i) state plan amendment (SPA) for adult mental health rehabilitation. Other funding includes federal block grants and state general funds.||Operates under a Medicaid SPA. The North Carolina Division of Medical Assistance pays CCNC a per member per month rate to cover care coordination and disease management activities. A portion of this fee supports CCNC's behavioral health program.||TennCare operates under a Section 1115 waiver.||Section 1115 waiver authorizes Medicaid funding. Centers for Medicare and Medicaid Services' Multipayer Advanced Primary Care Practice Demonstration authorizes Medicare funds. Vermont has a pending SPA to use the Medicaid Health Home option under the Affordable Care Act. All private insurers, Medicaid, and Medicare contribute funding for provider incentive payments and core CHT members.|
|The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/2014/4CaseStud.shtml.|