Strategies for Integrating and Coordinating Care for Behavioral Health Populations: Case Studies of Four States. E. Covered Populations and Services


Covered populations. All North Carolina Medicaid recipients with full benefits--including full dual eligible--are eligible to enroll in CCNC, with the exception of nursing home residents. As of March 2013, 1.3 million Medicaid recipients were enrolled in CCNC--over 75 percent of the state's Medicaid recipients. Therefore the demographic and other characteristics of CCNC's enrolled population largely reflect those of the broader Medicaid population. As of 2010, nearly a third of CCNC's adult non-dual eligible ABD enrollees--21,070 of 72,297--had a serious and chronic mental illness (Treo Solutions 2011).

Enrollment process. Individuals can sign up for CCNC at the time of Medicaid enrollment. All fully eligible North Carolina Medicaid recipients except full dual eligibles must choose a Medicaid PCP at Medicaid enrollment. Recipients may choose a CCNC-affiliated PCP or a non-affiliated PCP. Patients who do not choose a PCP are automatically assigned to a CCNC-affiliated PCP, but can later "opt out" and choose a non-CCNC-affiliated PCP if they wish. Though full duals are not required to choose a Medicaid primary care medical home, since they receive almost all of their primary care services from Medicare, they have the option to enroll in CCNC for Medicaid services not covered by Medicare.

Outreach. Outreach and educational efforts generally take place locally during the enrollment process. At this time, county eligibility workers guide Medicaid recipients through the process of choosing a medical home and educate them about the purpose of a medical home. Individuals enrolling electronically do not receive this educational piece. CCNC is seeking to increase outreach and education for potential enrollees. For example, CCNC has begun working with the state on an opt out process for full duals and institutionalized who were previously not eligible for CCNC. As part of this process, which has resulted in an opt out rate of only 10 percent, CCNC sends a letter to these individuals explaining the program and giving individuals 30 days to opt out before being automatically enrolled in the program.

Covered services. CCNC is financially responsible for providing care management services and care coordination for enrolled patients. This involves connecting patients with the medical, behavioral health, and local social services that they need. However, CCNC is not financially responsible for, nor does it directly provide, the medical, behavioral, or social services that it coordinates. DMA reimburses providers directly for medical services on a fee-for-service basis, whereas for behavioral health services, the state is currently transitioning to a managed care carve-out (Shipman 2012). Available social services vary by locale, but typically include housing assistance, heating assistance, food assistance, vocational rehabilitation, and educational supports. Since care managers work locally, they become very knowledgeable about what social services and supports are available, and connecting patients with these services is an important part of their work.

Coordination of services. CCNC's care management and coordination work relies heavily on its data and informatics center. This infrastructure allows CCNC to identify the patients in greatest need of care management and coordination, known as "priority patients" (see Section G). Priority patients are typically individuals with chronic conditions who are not experiencing optimal care patterns (for example, have been hospitalized or use the ED frequently), or who are outliers for cost of care based on clinical risk grouping. CCNC also identifies patients for care management based on provider referral. Each local network and its care managers work with the identified priority patients to make sure they are getting the care, medications, social services, and other resources they need. Typically care managers will work consistently with the same practices to facilitate continuity of care; a larger practice may have its own care manager, while smaller practices usually share a care manager.

Care managers, typically registered nurses or social workers, initiate the follow-up and make contact with practices concerning their panel of patients. CCNC's networks currently have a total of 600-800 care managers statewide. Care managers undertake a wide range of activities, including: (1) helping patients access needed care and coordinate services; (2) conducting patient education and follow-up to promote treatment adherence and support lifestyle changes; (3) conducting home visits (for example, to assess medication adherence); (4) arranging follow-up medical appointments, transportation services, and access to community-based social services; (5) managing care transitions; and (6) working with hospitals on discharge planning. To provide consistent guidance to care managers statewide, CCNC network leaders and program staff developed the Standardized Care Management Plan, which offers benchmarks and guidelines for care management activities (McCarthy and Mueller 2009).

Integrating care for individuals with SMI. Coordinating care for individuals with SMI in particular has been a challenge in North Carolina because the state's systems for physical health care and mental health care are distinct. Mental health services traditionally have been managed by LMEs, which are local government agencies responsible for managing, coordinating, facilitating, and monitoring mental health and substance abuse services (including maintaining adequate behavioral health provider networks) within a certain geographic area. The LMEs are governed by the Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (though behavioral health services for Medicaid recipients are funded by DMA). CCNC has traditionally managed the coordination of physical health services, which are governed by DMA. As a result, achieving mental and physical health care integration for individuals with SMI requires close collaboration between these two systems.

CCNC and the LMEs traditionally have used a four-quadrant model to determine whether patients should be managed by CCNC, the LME, or both. The model groups patients into four categories, those with: (1) low behavioral and physical health needs; (2) high behavioral health needs and low physical health needs; (3) low behavioral health needs and high physical health needs; and (4) high behavioral health and physical health needs. CCNC works closely with the LMEs to manage patients with both high behavioral health and physical health needs. To manage these patients, the state expects care managers from CCNC and the LME-MCOs to work together to create a "person-centered plan" which identifies the services and supports needed to help an individual achieve his or her goals and live independently. Both sets of care managers are expected to stay engaged to make sure the consumer gets all necessary physical and behavioral health services. CCNC is primarily responsible for managing the needs of consumers with high physical health needs but low behavioral health needs. CCNC will refer consumers with high behavioral health needs but low physical health needs to the LME case managers, and will stay engaged throughout to ensure that the individual receives necessary specialty behavioral health services. CCNC's patient portal (see Section G) allows all providers and case managers (including behavioral health providers and LME care managers) to view service utilization information for individual consumers, including their use of behavioral health services and prescription drugs. CCNC estimates that 80 percent of specialty behavioral health providers currently use the patient portal to aid in clinical decision-making.

As of June 2013, the state is transitioning all LMEs into 11 separate full-risk managed BHOs known as LME-MCOs. For several reasons, this change has added a layer of complexity to CCNC's efforts to integrate physical and mental health services for consumers with SMI. First, consumers' need for mental health services will need to undergo a utilization review by the LME-MCO which can delay treatment. Second, each LME-MCO has a different set of policies regarding eligibility for care management. In some cases, the LME-MCO may not agree with CCNC that a consumer needs to be assigned a care manager. Prior to the transition, CCNC and the LMEs generally agreed on the criteria for selecting patients for care management.

In response to the state's conversion of LMEs into Behavioral Health MCOs, CCNC is implementing several activities to address these challenges. In one county, CCNC's local network is collaborating with the local LME-MCO to integrate care management services for consumes with high physical health and behavioral health needs. CCNC is looking to expand this model to other LME-MCOs in the future if CCNC can obtain their buy-in. In addition, CCNC's informatics staff are building reports for the LME-MCOs that will provide them with a "preferred patient list" a list of high-risk patients with behavioral health needs that are likely to require management--for example, those who have had high ED or hospital utilization for these issues. Each CCNC network meets at least monthly with its local LME-MCO counterpart to discuss communication, referrals, and coordination as well as to address individual cases. At the agency level, CCNC meets monthly with DMA and the Division of Mental Health, Developmental Disabilities, and Substance Abuse to address broader issues, for example creating a universal referral form for all case managers and providers to use.

Behavioral health program. Through its behavioral health program, CCNC aims to facilitate integration of primary care and behavioral health care. CCNC does this by supporting PCPs in becoming the medical home both for enrollees with mild to moderate behavioral health issues typically served in the primary care system as well as those with SMI, particularly those with physical comorbidities, that are typically served in the specialty behavioral health system (CCNC 2013e). To achieve this aim, CCNC trains and supports the primary care medical homes in treating stable behavioral health conditions and substance abuse and helps PCPs feel more comfortable treating people with SMI. The program includes a strong educational component--for example, CCNC holds lunchtime trainings at practices on topics such as screening for substance abuse.

The behavioral health program is directed from the central office by a psychiatrist who leads a team comprised of a second psychiatrist and associate director, a behavioral health pharmacist, and a behavioral health care coordination program manager (CCNC 2013e). In addition, each network has its own psychiatrist and behavioral health coordinator who work on integrating care at the local level. The network psychiatrists: (1) develop collaborative relationships with LMEs; (2) identify best practices in screening and psychopharmacology for use in provider networks; and (3) facilitate engagement with community psychiatrists and key stakeholders. The behavioral health coordinators: (1) identify enrollees requiring care management; (2) help enrollees navigate the mental health and substance abuse systems; (3) employ motivational interviewing with enrollees to encourage self-management; and (4) assist PCPs in managing behavioral health needs. In addition, CCNC has incorporated behavioral health flags into its electronic care management tool. For example, the tool flags emergency room visits for mental health or psychiatric medication prescriptions to help identify members needing care management (Hamblin, Verdier, and Au 2011).

Specific behavioral health initiatives include:

  • Integrated Care/Co-Location. CCNC is working to create a service delivery system that closely coordinates behavioral and physical care. The model involves a team-based approach in which physical and behavioral health providers partner to facilitate the direction, treatment, and follow-up of psychiatric disorders in the primary care setting. The model is appropriate for treating mild to moderate psychiatric disorders or maintaining the treatment of severe psychiatric disorders that have been stabilized. For individuals with severe psychiatric disorders that have not been stabilized, CCNC's care managers work with the LME care managers to create a person-centered plan and to ensure that the individual is getting the specialty behavioral health services that they need. If any physical comorbidities are present, CCNC's care managers work to assess care needs and arrange treatment for these conditions. Though the model implies that services are centered on the primary care setting, the important factor is not where the services are delivered, but how--there must be close coordination and collaboration between physical and behavioral service providers resulting in a seamless continuum of care for the patients (CCNC 2013e).

  • Adult Safety with Antipsychotic Prescribing (ASAP). North Carolina Medicaid has initiated a prior-authorization policy for prescription of second-generation antipsychotics for off-label use (for example, to treat insomnia, anxiety, or primary treatment of depression). Under this initiative, the prescribing physician must obtain prior-authorization from a contractor of North Carolina Medicaid before the prescription can be dispensed. The initiative aims to reduce the inappropriate use of antipsychotics and reduce prescription drug costs for the state (CCNC 2013e).

  • The North Carolina ACCEPT Project. This program employs educational campaigns targeting psychiatric professionals to encourage them to change prescribing trends for specific diagnoses including sleep disorders, depression, and treatment-resistant depression. The goal of the program is to move toward evidence-based and cost-effective prescribing practices, thereby improving psychiatric care and producing cost savings for the state. This program, funded by CCNC, is a partnership with the state's four academic medical centers (CCNC 2013e).

  • Depression Toolkit for Primary Care. The CCNC Depression Toolkit was designed to help PCPs access practical, evidence-based tools to help them successfully treat adult major depressive disorder (MDD). The kit includes implementation recommendations, an algorithm to help with the initial assessment of MDD severity, a corresponding recommended treatment approach, screening tools, medication recommendations, etc. The kit also includes a guide to help PCPs decide when a referral for psychiatric care is indicated (CCNC 2013e).

Network pharmacist program. CCNC has implemented a pharmacy program which aims to create a medication management infrastructure that improves care outcomes while reducing total health care costs, not just prescription drug costs. Due to the high cost of many behavioral health medications, this program is particularly relevant for those with behavioral health needs. The program places a pharmacist within each CCNC network to aid the care management process. The pharmacists help physicians create and manage drug regimens for patients with chronic illness, perform medication reconciliation assessments, educate community pharmacists on Medicaid and CCNC pharmacy initiatives, and serve as a general resource for prescription drug and policy information. In addition, CCNC has implemented a number of specific initiatives through this program, such as the Prescription Advantage List (PAL). The list, which is optional for providers to use, ranks drugs within therapeutic categories (by highest frequency and opportunity to impact quality and cost) to encourage the use of less-expensive drugs, including generics and over-the-counter medications, whenever appropriate. CCNC providers receive quarterly feedback on a PAL scorecard showing the percentage of prescribed PAL drugs and the use of over-the-counter medications for their enrolled population (McCarthy and Mueller 2009).

Eligibility for providers. Any licensed Medicaid PCP can become a CCNC-affiliated primary care medical home. In order to qualify, providers must agree to actively participate in CCNC's care coordination and disease management initiatives, refer patients to CCNC for care management as needed, and offer after-hours care (24 hours a day, seven days a week) to reduce unnecessary ED utilization.

Interaction with other federal demonstrations. North Carolina has several federal demonstrations that interact with CCNC's work. First, the state has a five-year Medicare Quality Demonstration (646). The goal of this project is to improve the quality of care and patient outcomes for both dual eligibles and Medicare-only beneficiaries by using the CCNC model to address gaps in care, quality, and efficiency (CCNC 2013c). The program allowed CCNC to access and incorporate Medicare claims data into its informatics center to better manage and serve its dual eligibles as well as the newly enrolled Medicare-only population. North Carolina has a number of FQHC Advanced Primary Care Practice demonstrations, all of which are CCNC primary care medical homes. CCNC is working closely with these practices on implementing their demonstrations, primarily on incorporating practices' clinical and claims data into the state's Health Information Exchange, which CCNC runs. Access to these data in a clinically useable format will give the practices a platform to carry out necessary clinical and care improvement activities. North Carolina was recently approved for a CMS Demonstration to Integrate Care for Dual Eligible Individuals, which will use CCNC's medical homes model to coordinate care across primary, acute, behavioral and long-term supports and services for dual eligible individuals, incorporating a unique financing arrangement. Finally, effective October 1, 2011, CMS granted North Carolina approval for a SPA to implement the Health Homes provision through Section 2703 of the ACA. This SPA grants North Carolina an enhanced federal match (90 percent) for health home services for eligible Medicaid beneficiaries. To be eligible, beneficiaries must have two qualifying chronic conditions or one qualifying chronic condition and risk for a second. However, the SPA excludes mental illness and substance abuse disorders from this program (HHS, CMS 2012).

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