Missouri: Statewide Involvement
Missouri state officials did not have to be convinced of the merits of the CCBHC demonstration program. "Establishing CCBHCs was the next logical step for Missouri," said Dorn Schuffman, state contact for the demonstration program. "We already had in place many pieces that contribute to greater access to improved care, such as the Health Homes initiative and a crisis response system. It just made sense for us to tap the benefits of moving from a FFS model to a prospective payment system."
Years of hard work preceded Missouri's designation as a demonstration state. In October 2011, Missouri became the first state in the nation to receive approval from CMS for Medicaid reimbursement of Health Homes. Community Mental Health Center (CMHC) Healthcare Homes[a] help individuals with SMI more effectively engage with physical health care, MH/SUD care, recovery supports, and social services and other supports. Because of the significant improvement in health outcomes and substantial Medicaid savings the CMHC Healthcare Homes program was able to demonstrate, Missouri received the American Psychiatric Association's 2016 Gold Achievement Award[b] for community-based programs.
Fiscal year 2014 marked the start of a multi-year investment in Missouri's Strengthening Mental Health Initiative,[c] which featured several innovations:
Extensive training has been a hallmark of Missouri's journey to better care. By the end of the demonstration, training is expected to raise fidelity-level performance of integrated treatment for co-occurring disorders (simultaneous SUD and mental health treatment rather than fragmented services) among CCBHCs from 57 percent to 100 percent. Senior leadership from all CCBHCs now participate in trauma-informed care and zero suicide learning collaboratives.
During Missouri's CCBHC planning process, individuals with lived experience, their family members, and stakeholders from social service and related support organizations expressed a need for additional peer specialists and family support providers. Prior to the launch of the demonstration, fewer than a third of the participating clinics employed family support providers (specially trained parents with lived experience who serve the families of children with SED) and fewer than half employed certified peer specialists. Due to extensive recruitment and training opportunities prompted by the demonstration program, all CCBHCs have started working with family support providers and peer specialists or expanded existing peer specialist and family support staffing.
Having more staff creates the ability to provide more services, and this extends to licensed professionals, as well. Moving to the PPS allowed the clinics to provide competitive salaries for key positions when warranted, thereby attracting more psychiatrists and other licensed professionals.
Schuffman noted that the most dramatic improvements were driven by the move from FFS payment for individual services to a bundled encounter rate that is cost-based. He says, "Providers are really excited about this change. It has enabled them to focus differently on the population they serve. Patients, too, are more confident in knowing their provider is there for them."
Adopting a PPS may have been more challenging for Missouri than other demonstration states because of its intention, from the beginning of the CCBHC planning process, to include the entire state in the demonstration. This meant a massive, statewide overhaul of all billing and data-reporting systems. Missouri's CCBHCs use Care Manager, a data collection system piloted during the planning grant period, to harness various data feeds.
During the first year, Missouri projected serving approximately 130,000 clients. Reflecting 2 percent of its population, this percentage is ten times greater than many of the other demonstration states' projections. Of the 27 potential service areas in Missouri, 19 are included; a state plan amendment is being drafted to maintain the model at the end of the demonstration and add the remaining eight service areas.
"We felt empowered to set our sights on the entire state by our level of readiness," reflects Schuffman. "All of our CCBHCs were already serving as Health Homes. Crisis response was operational statewide. No less important, the Department of Mental Health, the Department of Social Services, and the Missouri Coalition for Community Behavioral Healthcare--all key players of the CCBHC project leadership team--have a long history of collaboration. We know how to work together to overcome challenges, to make wellness obtainable for all Missourians."