December 2012: Health Homes
Health Homes: What Healthcare’s “One Stop Shopping” Models Mean for Behavioral Health
Charles Ingoglia, MSW, Senior Vice President for Public Policy and Practice Improvement, and Laira Roth, Policy Associate, National Council for Community Behavioral Healthcare
Individuals with multiple chronic conditions represent our healthcare system’s most costly and complex cases. Recent studies show that comorbid behavioral and medical conditions are the expectation — not the exception. In fact, 68% of people with a mental illness also have a physical health condition such as cardiovascular disease, diabetes, and hypertension. These high-need individuals often receive uncoordinated, inefficient care, resulting in higher costs and poorer health outcomes. If we want to improve the care of patients and the overall health of our nation, we must focus on improving care for this population.
Section 2703 of the Affordable Care Act allows us to focus on this population through the Medicaid “health home” option to help states manage and improve care for beneficiaries experiencing two or more chronic conditions, including behavioral health disorders. A health home must provide beneficiaries “one-stop shopping” by maintaining responsibility of providing the full range of services. States with approved Medicaid health home state plan amendments (SPAs) will now receive a 90% federal match for services not previously covered under Medicaid such as care coordination, comprehensive care management, and patient and family support. This approach has the potential to reduce emergency room usage, hospital admissions, and reliance on long-term care facilities, as well as to improve the experience and quality of care for those beneficiaries targeted under the state’s health home.
The Medicaid health home option presents a unique opportunity for behavioral health. With strong focus on Medicaid beneficiaries’ behavioral health needs and emphasis on care coordination, behavioral health organizations could play a vital role in establishing these new service delivery models. The Medicaid option is largely modeled on the patient-centered medical home (PCMH) — which builds on the chronic care model — and supports five key themes for quality care in a health home: (1) self-management support, (2) shares decision-making, (3) delivery system redesign, (4) embedded clinical guidelines, and (5) the use of client registries to organize data.
It is particularly important for behavioral health organizations to prioritize data collection when considering health home participation. As new service delivery models such as health homes and accountable care organizations become more prominent and funding streams become increasingly aligned with health outcomes, healthcare providers will need to demonstrate the ability to collect, organize, and use data to inform treatment. The collection and use of data will prove beneficial as providers strive to market themselves as potential partners in these new service delivery models. They will need to demonstrate the ability to improve health outcomes in a financially efficient manner.
What Health Homes Mean for Behavioral Health Organizations
To become involved in health home activities, you must determine whether your state is considering establishing a health home for individuals with behavioral health disorders. Rhode Island and Missouri are just two of the states with approved Medicaid health home SPAs that place particular focus on addressing behavioral health needs and enable behavioral health providers to become health homes. In Missouri, 27 community mental health centers have been designated as health homes and coordinate the full range of healthcare services for individuals eligible for health home services. States interested in establishing a health home for individuals with a behavioral health disorder must consider what a behavioral health home would look like and what core clinical features are needed to ensure effective, high-quality care.
In states where behavioral health organizations are ineligible to serve as health homes, you can still become a health home partner. CMS health home regulations require that states adequately address the target population’s behavioral health needs. You will need to identify ways to partner with designated health homes, which requires the ability to share data, report on quality measures, and implement self-management training and support. In addition to potential state level efforts, you should also prepare for opportunities to engage in recognition programs around health homes. The National Committee for Quality Assurance (NCQA) has established a medical home recognition program in which healthcare providers can become recognized as patient-centered medical homes upon meeting standards that ensure the full coordination and delivery of healthcare services for clients served. You can also engage in community-level initiatives to promote health homes.
Health homes bring the promise of well-coordinated, high-quality care for individuals who suffer from the most complex illnesses. The inclusion of behavioral health treatment is a keystone for this service delivery model and behavioral health organizations will play an important role in these statewide initiatives.
While a relatively new model, health homes are based on proven healthcare delivery strategies and have core clinical features and key considerations that your behavioral health organization must contemplate.
Collaborate with Each Patient on Care
At the center of the health home model is the notion of person-centered care in which treatment and services are based on an individual’s preferences, needs, and values; the client is a collaborative participant in healthcare decisions and an active, informed participant in treatment itself.
Develop Partnerships and Identify an Integrated Model
Partnerships with primary care and other healthcare specialty areas are instrumental in addressing individuals’ comprehensive healthcare needs. Your organization will need to identify the type of integrated care model to participate in (e.g., in-house, co-located partnership, or facilitated referral).
Know Your Population
What population do you currently serve? It’s important that you define the demographics and provide population-based data about the target service group for your behavioral health home.
Use Data Effectively
Establish effective strategies for collecting, organizing, sharing, and applying objective, valid clinical data to guide treatment and inform clinical decisions. This includes the standardized use of validated clinical assessment tools to monitor response to treatment and information systems such as registries to track data over time.
Define Core Practice Teams
A key health home component is the delivery system’s design. Who makes up the multidisciplinary team that shares responsibility for clients and how will care management fit into the delivery system design? For many behavioral health organizations, an external primary care partner may need to be included in the team make-up.
Establish Clear Financing Structure and Payment Rates
There are key financing considerations when establishing health homes and it is imperative to research different payment methodologies (e.g., per member per month payments, capitated) and reimbursement rates for different services within your state.
Under the State Demonstrations to Integrate Care for Dual Eligible Individuals, the Centers for Medicare and Medicaid (CMS) selected 15 states to develop new ways to meet the complex, costly healthcare needs of the 9 million Americans eligible for both the Medicare and Medicaid programs (“dual eligibles”), including those with behavioral health needs. In California, the Health Plan of San Mateo, in close collaboration with SAMHSA Primary and Behavioral Health Care Integration (PBHCI) grantee San Mateo County Health Systems, was selected for this important state Demonstration Project.
San Mateo County Health Systems and the Health Plan of San Mateo, the county’s only health plan, worked with beneficiaries, their families, and other stakeholders to develop their demonstration proposal, which is now in the implementation phase. The program aims to eliminate duplication of services for dual eligibles, expand access to care, and improve the lives of dual eligibles — all while lowering costs. Such an endeavor is a tall order, but one that was made easier, in part, by San Mateo Health System’s existing relationship with the health plan and its participation in the SAMHSA PBHCI program.
San Mateo County Health Systems views the Demonstration Project as a “macro” version of the PBHCI program and sees care coordination as central and a means to create order among the multiple care managers for clients with multiple healthcare needs. They strive to develop and realize a system that optimizes the role of care managers and helps them work with each other. The care manager associated with a client’s most pressing health problem takes the lead and coordinates care with care managers in other health fields (e.g., geriatrics, cardiology).
For other PBHCI grantees considering taking on such activity, Dr. Chris Esguerra, Deputy Medical Director and PBHCI Project Director San Mateo County Health Systems, says, “It’s a lot of time, effort, end energy, but the benefits are evident.” He explains that PBHCI grantees are already doing the work required by the Demonstration Project. The dual elgibiles project, which focuses on life-long care, is merely on a greater scale. And, they see the benefits as tremendous: better care and outcomes for a vulnerable population, greater public appreciation of the value that integration programs provide, and a platform upon which to build and strengthen relationships and to determine what works best in healthcare delivery.
Learn more about the SAMHSA Primary and Behavioral Health Care Integration program. Visit smchealth.org for more on San Mateo Health Systems.
Financing and Policy Considerations for Medicaid Health Homes for Individuals with Behavioral Health Conditions (December 19, 3:00-3:30 pm EST)
A recently enacted provision of the Affordable Care Act allows states to establish Medicaid health homes, a service delivery model that involves care coordination and related supports for individuals with chronic conditions. CIHS developed a paper that outlines the key financing and policy considerations for state policymakers and stakeholders who are interested in pursuing a Health Home State Plan Amendment for individuals with serious mental illness and other chronic health conditions. This webinar will walk through coding and reimbursement information and how they would work for health homes that include mental and substance use disorder benefits, as well as look at Ohio’s experience in addressing these financial and policy considerations and how they have been operationalized for providers on the ground.
Did you miss past CIHS Webinars on topics such as motivational interviewing, billing for integration services, health behavior changes, and much, much more? Go to www.integration.samhsa.gov/about-us/webinars to access recordings, presentations, transcripts and more.
Behavioral Health Homes for People with Mental Health & Substance Use Conditions: The Core Clinical Features prepares behavioral health provider organizations to become health homes by outlining the essential clinical features. In addition, the paper introduces several real-world examples of how behavioral health provider organizations are successfully implementing the clinical features of a health homes around the country.
WHAM! The Latest for Curriculum to Support Peers
CIHS’s new peer support curriculum — Whole Health Action Management (WHAM) – promotes whole health self-management and strengthens the peer workforce’s role in integrated healthcare delivery by preparing them to use person-centered planning to set achievable whole health goals and weekly action plans to create new health behavior by engaging in weekly WHAM groups. It also teaches basic health screens for prevention and shared decision making with health professionals. Learn more about WHAM or contact Hannah Mason at email@example.com with questions.
New Peer Specialists Resource
The NIDRR-funded Rehabilitation Research and Training Center on Participation and Community Living of Individuals with Psychiatric Disabilities announced the publication of Helping People Connect to the Religious Congregations and Spiritual Groups of Their Choice: The Role of Peer Specialists, a new monograph exploring the roles of peer specialists in helping the people they serve to connect to the mainstream religion congregations and spiritual groups of their choice. This monograph is part of a series of documents that explores peer specialists’ roles in promoting community inclusion of service recipients in a variety of life domains.
CPT Code Changes Resources
CPT codes will change on January 1, 2013. To help behavioral healthcare professionals understand and comply with the news codes, the National Council for Behavioral Health has put together a CPT resource page that includes a fact sheet, FAQs, webinar recordings, CMS E/M documentation guidelines, and more.
New Toolkits: The Health Care Workforce Shortages
Four new Alliance for Health Reform Toolkits provide the information you need to understand why workforce shortages are occurring, how serious they are, and the prospects are moving forward. They include fast facts, lists of knowledgeable experts, and links to timely articles and reports.
- HIT Workforce Toolkit details recent findings on how staff shortages are becoming a bigger barrier than implementation costs of health IT as electronic medical records.
- Physician Workforce Toolkit forecasts a physician shortages of more than 90,000 within the next 10 years. It identifies challenges and proposed solutions to increase the workforce.
- Nursing Workforce Toolkit projects that 260,000 additional nurses will be needed by 2025 to meet healthcare needs.
- Direct Care Workforce Toolkit explains the increasingly important contribution of the direct care workforce to coordinating care in a high quality healthcare system, and describes challenges and solutions in the health law to assure an adequate workforce.
Fact Sheet Address Medicaid Primary Care Rate Increase
On November 1, the Centers for Medicare & Medicaid Services (CMS) released final regulations outlining how it will implement the Affordable Care Act’s Medicaid primary care rate increase. The Center for Health Care Strategies released a fact sheet summarizing the regulation, highlighting select provisions for states to consider when planning implementation. The fact sheet describes eligible providers, eligible evaluation and management services, how the rule applies to managed care, and more.