Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. B. State Context


Program background. CCNC evolved from a small medical homes program (the Wilson County Health Plan) in one rural county in the early 1980s. The medical homes program connects each patient with a PCP who leads a health care team in addressing all of the patients' health needs. The program was a joint partnership between the state Medicaid agency (the Division of Medical Assistance [DMA]), the Office of Rural Health, Research, and Development, and the North Carolina Foundation for Advanced Health Programs, Inc., with a private health care philanthropy (the Kate B. Reynolds Health Care Trust) providing the funding. The program's aim was to encourage physician participation in Medicaid, thereby improving access to care and reducing reliance on ED utilization. The program expanded in 1989 to become a statewide PCCM program (Carolina Access) which added a PMPM payment to PCPs to fund care coordination activities. In 1998, the current CCNC program was officially piloted in seven rural counties in response to a North Carolina Department of Health Services directive calling for the state to improve Medicaid access and quality and to lower costs. The CCNC pilot added several new elements to Carolina Access: (1) regional physician networks; (2) population management tools; (3) care management and clinical support; and (4) data and feedback (CCNC 2013b). The CCNC model worked well in North Carolina, a predominantly rural state, because it was adaptable to both urban and rural contexts. The program has also experienced high participation rates by PCPs, indicating their satisfaction with the program. In contrast, the state's comprehensive MCOs had difficulty penetrating the state's rural markets and eventually voluntarily withdrew from the Medicaid program.

CCNC was expanded statewide in 2001. Originally, CCNC worked only with non-disabled adults and children and focused on single chronic illnesses such as asthma and diabetes. However, it soon became clear that most cost and quality issues were related to treatment of multiple chronic illnesses. In 2005 the state expanded CCNC's role to the aged, blind, and disabled (ABD) populations, including full dual eligible beneficiaries. Also in 2005, in response to a growing need for data and informatics, CCNC's leadership shifted from the state agency to a newly formed not-for-profit organization acting as a central office. CCNC's behavioral health program was added in 2010 as part of an effort to improve quality of care and reduce health care expenditures for individuals with behavioral health care needs, including those with SMI.

Basis in other models. CCNC's founders initially looked to California's county-organized health system model to gather ideas. In the early 1980s, when the Carolina Access founders were developing the program, California was the only state undertaking a similar project to coordinate care using county-based entities. CCNC's behavioral health program was not modeled on that of other states but developed organically in response to the cost and quality issues related to treating the SMI population. CCNC realized that in order to address these issues, it needed to develop better ways to engage mental health providers.

Partnering agencies and organizations. CCNC's development was made possible through multiple state and private partnerships. The North Carolina Medicaid agency (DMA in the Department of Health and Human Services) was a founding partner and currently funds and oversees CCNC's contract. The Office of Rural Health and Community Care (ORHCC), another founding partner, currently works with CCNC on specified initiatives and recently provided funding for a chronic pain initiative. ORHCC also contracts with CCNC for the use of its "provider portal" (see Section G), allowing PCPs to use this tool to manage uninsured patients in addition to the Medicaid patients that CCNC manages. The North Carolina Foundation for Advanced Health Programs, Inc., another early partner, has sponsored much of CCNC's piloting and testing. Most recently, the foundation has partnered with CCNC on the Integrated, Collaborative, Accessible, Respectful, and Evidence-based (ICARE) Partnership to educate providers on care integration (North Carolina Foundation for Advanced Health Programs 2013). The Kate B. Reynolds Health Care Trust was CCNC's first funder, providing six grants totaling $1.6 million during the program's early development (CCNC 2013b). CCNC also works with the North Carolina Division of Mental Health, Developmental Disabilities, and Substance Abuse to coordinate policies and care management procedures, particularly in light of the state's shift to behavioral managed care.

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