1. health and fitness

3/11/2014
Key Components of NYS Medicaid
Redesign and the Opportunity for
Culturally Competent Approaches
(includes new OMH guidance)
Behavioral Healthcare Reform and
Culturally Competent Care Conference
Harvey Rosenthal
Briana Gilmore
28 February, 2014
www.nyaprs.org
Why are Changes Coming to
Your Medicaid Healthcare?
US and New York state budgets can no
longer keep up with Medicaid’s rising costs
 At the same time, too many Medicaid
beneficiaries don’t get or participate in
enough of the right kind of healthcare
 As a result, too many spend too much time
in expensive visits to emergency rooms
and hospitals

1
3/11/2014
ACA Healthcare Reforms
Major Federal Drivers




Triple Aim: improving outcomes,
improving quality, reducing cost
Medicaid/managed care expansion, BH
parity
Focus on better coordinated, accountable
and integrated physical and behavioral
health care
Major emphasis on home and community
based services and less reliance on
institutional care
3
The Need for Healthcare Reform
Special Focus on People w BH Conditions





$54 billion Medicaid program with 5 million beneficiaries
20 percent (1 million beneficiaries) use 80 percent of these dollars
o Hospital, emergency room, medications, longtime “chronic”
services
o Over 40% with behavioral health conditions
NYS avoidable Medicaid hospital readmissions: $800 million to
$1 billion annually
◦ 70% with behavioral health conditions; 3/5 of these
admissions for medical reasons
Thousands of adult and nursing home residents with psychiatric
disabilities who can successfully live in the community with
appropriate individualized supports
85 percent unemployment, high homelessness, incarceration
rates
4
2
3/11/2014
Guiding Principles of NYS
Managed Care Redesign

Person centered care management

Integration of physical and behavioral health
services

Focus on Recovery

Patient/consumer choice

Protection of continuity of care

Ensure adequate and comprehensive networks

Reinvest savings to improve BH system
5
NYAPRS’ Agenda for
NYS Medicaid Redesign






Consumer rights and protections, including
freedom of choice, informed consent, and
person-centered treatment plans;
Prioritization of recovery-oriented, community
based services and self-directed care;
A critical role for peer professionals;
Reinvestment of savings back into the BH
system to improve service capacity;
Provide and advocate for training of providers in
recovery-oriented approaches and models
Ensure that BH delivery is provided in a culturally
competent manner, providing personcenteredness to peoples of all ethnic, religious,
geographic, and age groups.
3
3/11/2014
Where are We Now?
Self
MH
Lifestyle
Alternatives
Social
Spiritual
Self Help
Clinic
Clinic
PROS/CDT
Opioid Tx
Club/Employment Detox
Recovery Center Rehab
Other peer svces
Case Management
ACT
Housing
Hospital
Emergency
SU
Medical
Primary Care
Specialty Care
Hospital
Urgent/ER care
Pharmacy
Segregated, Site Based, Siloed
Uncoordinated, Visits not Outcomes
NYS Medicaid Redesign
From Fee for Service to Managed Care


Medicaid pays for 48% of public mental health
system in NY.
Fee for Service: providers get paid for the
amount of service that’s offered…not the
outcomes.
◦ People can choose services/duration, providers

NYS FFS Behavioral Health program currently
spends about $4 billion for the BH care of
700,000 beneficiaries with more serious or
ongoing mental health/addiction related needs
4
3/11/2014
NYS Medicaid Redesign
From Fee for Service to Managed Care

NYS Medicaid Health Plans will be
adding FFS behavioral health services to
medical and pharmacy services that
they are already overseeing (+$20-30k
per person per year)
Managed Care

Managed Care
Organizations are
companies that
contract with employers
or government to
organize and authorize
healthcare for their
employees or
beneficiaries (Medicaid,
Medicare) in ways that
are intended to
promote health while
controlling costs

Typical MCO functions
are:
◦ Member services (intake,
referral, crisis
◦ response)
◦ Utilization management
◦ Medical management
◦ Network management
◦ Quality management
◦ Data management
◦ Reporting and financial
management
5
3/11/2014
Qualified MCOs Will Add Basic
Behavioral Health Benefit






Inpatient - SUD and MH
Clinic – SUD and MH
Personalized Recovery
Oriented Services
Assertive Community
Treatment
Partial Hospitalization
Comprehensive Psychiatric
Emergency Program




Targeted Case Management
Opioid treatment
Outpatient chemical
dependence rehabilitation
Rehabilitation supports for
Community Residences
(phased in in 2016)
11
NYS Medicaid Redesign
Managed Health and Recovery Plans
(HARPs)


Health Plans can apply to offer Health and Recovery
Plans for individuals with more significant needs.
Plans may operate services directly only if they meet
rigorous standards.
o

Plans that do not meet rigorous standards must partner with
a BHO which does meet those standards.
Health plans that want to operate a HARP will be
demonstrating they meet the state’s qualifications
between March to June
12
6
3/11/2014
13
2011 Top 20 Health Plans –
HARP/non-HARP
Plan Name
FIDELIS
HEALTH FIRST PHSP INC
METROPLUS HEALTH PLAN INC
AFFINITY HEALTH PLAN INC
HEALTH PLUS PHSP INC
BLUE CHOICE/BLUE CHOICE OPTIO
UNITED HEALTHCARE OF NY INC
HLTH INSURANCE PLAN OF GTR NY
NEIGHBHD HLTH PROVIDER PHSP
HUDSON HEALTH PLAN INC
CAPITAL DISTRICT PHYS HLTH PL
HEALTHNOW NY INC
SYRACUSE PHSP
INDEPENDENT HLTH ASSOCIATION
MVP HEALTH PLAN, INC
AMERIGROUP NEW YORK LLC
BUFFALO COMMUNITY HEALTH INC
WELLCARE OF NEW YORK INC
UB FAMILY MEDICINE
NY PRESBY SYS SELECT HLTH SN
HARP non-HARP
19,904
54,279
14,409
33,138
11,262
27,756
7,330
20,476
6,605
18,754
6,777
18,338
6,238
16,127
7,174
14,433
5,482
12,678
3,165
9,701
3,077
7,832
1,926
5,812
2,011
5,506
1,886
5,521
1,754
4,918
1,688
4,866
1,279
4,439
1,323
3,478
1,764
1,770
1,472
1,466
Behavioral Health Organizations
 Magellan
Health Services
 OptumHealth
 ValueOptions
 Community Care Behavioral Health
 Beacon Health Strategies
7
3/11/2014
Key Requirements of All HARPs
•
•
•
•
Individual plans of care and care coordination
must be person-centered and address both inplan benefits and non-plan services, e.g.,
housing, employment, etc.
Plans must interface with social service systems
to address homelessness, criminal justice
involvement, and employment-related issues on
behalf of their members
Plans must interface and collaborate with Local
Governmental Units (LGU)
Plans must interface with state psychiatric centers
to coordinate care for members
Footer Text
21
HARP Eligibility Criteria







SSI Recipient receiving MH services past yr
3 months of ACT, TCM, PROS, PMHP in past
year
30+ days of psych hospitalization in past 3
years
3+ psychiatric admissions in past 3 years
60+ days in OMH psych center
Outpatient commitment order
Incarceration w BH treatment past 4 years
8
3/11/2014
HARP Eligibility Criteria, continued
OMH funded housing program past 3
years
 2+ SUD related inpatient stays
 2 Emergency Dep’t visits in past year for
SUD
 2+ detox stay in last year
 1 inpatient stay with SUD primary dx
 Transition age young adult with HCBS,
RTF history

HARP Enrollment
‘Passive’ or ‘Auto-Enrollment’ by the Plans
 People can opt to stay in their
mainstream plan or choose another
HARP
 Members get 90 days to opt out of the
HARP
 Once enrolled, they are locked into the
plan for a year

9
3/11/2014
NYS Proposed 1915.i HCBS Option
Enhanced Medicaid Benefits for HARPs
Rehabilitation
Psychosocial Rehabilitation
Community Psychiatric Support
and Treatment (CPST)
Residential Supports/Supported
Housing
Habilitation
Crisis Intervention
Short-Term Crisis Respite
Intensive Crisis Intervention
Mobil Crisis Intervention
Educational Support
Services
Support Services
Family Support and Training
Non- Medical Transportation
Individual Employment
Support Services
Prevocational
Transitional Employment Support
Intensive Supported Employment
On-going Supported Employment
Peer Supports
Self Directed Services
Additional 1915.i Related
Outcome Measures for HARPs
◦ Participation in employment
◦ Enrollment in vocational rehabilitation services
and education/training
◦ Improved or Stable Housing status
◦ Access to and use of Peer Support
◦ Longer Community tenure, Decreased Hospital
Readmissions
◦ Decreased Criminal justice involvement
◦ Improvements in functional status
◦ Cultural & Linguistic Competence, Engagement?
10
3/11/2014
Key Roles for Peer Services
Examples of Peer Run Specialty Services







Peer Crisis Diversion: warm lines, respite house, ‘living room’ ER alternatives
Peer Bridging: from state and Medicaid hospitals, adult and nursing homes, homeless shelters, criminal justice settings
Peer Wellness/Recovery Coaches
Rights Protection and Advocacy: Ombudspersons
Life Coaching: work, economic self sufficiency
Peer Supported Housing
Peer ombudspersons
21
2014 Ramp up for 1915.i Services
Building Adequate Capacity
Build up 1915.i-like services network
capacity
 Funding for the development of functional
assessments to establish 1915.i eligibility
 Fund 1915.i services starting in January
2015

11
3/11/2014
1915.i Funding
HARP monthly capitated payments will
not include funding for 1915.i services
during 2015-6,
 They will have cost limits during this
period
 Starting in May, NYS will pilot test NYS an
assessment tool to project these costs
 They will ‘likely’ move into capitation
starting in 2017

1915.I Manual, Approved Providers



NYS is developing a manual with guidance
documents to clarify services, procedure
coding, pricing, staffing and data reporting
NYS will develop a designation process to
identify providers qualified to deliver HARP
1915(i) HCBS services, starting with
OMH/OASAS providers ‘in good standing’
Plans will be able to supplement this
provider roster with additional providers
meeting equivalent qualifications and training
12
3/11/2014
How Health Plans will Authorize
Payment for 1915.i Services
NYS will provide level of care guidelines that
Plans must follow
• Plans must demonstrate they are approving
enough of the right kind of 1915.i services to
ensure that the person centered plan of care
meets individual needs
• 1915(i) services will be identified with
distinct codes
• NYS will review and approve all Plan level of
care guidelines for 1915(i) services
•
Proposed 1915.i Outcome Measures




Employment/Education: % of members who
maintained or improved employment status
or education seeking status
Housing: % of members with improved
housing status
Criminal Justice: % of members with reduced
arrests
Drug and Alcohol Use: Change in
Abstinence–Alcohol and Other Drug Use;
Recommend using for only those with a
diagnosis of SUD
13
3/11/2014
Proposed 1915.i Outcome Measures



Social Connectedness: % of members with
improved social engagement in the past 30
days
Overall Improvement in Functional Status: %
of members with improved levels of
functioning from baseline measurement to
12 months
Member perception of positive change: deal
with daily problems, better control of life;
better dealing with crisis, get along with
family, symptoms improved)
Member Service Center
• RFQ will clarify that Plans are not
required to have a separate BH service
center
• Centers must be appropriately staffed to
handle volume, operate 24/7, and have
culturally competent staff.
• Center staff must receive training on
HARPs and be knowledgeable about local
populations, crisis services and local
service systems
14
3/11/2014
Medicaid Health Homes

A Medicaid health home is not a place, but
a philosophy of health and health care that
encourages providers to help people with
multiple and persistent conditions to "feel
at home" with their healthcare .
Medicaid Health Homes
 Health
homes provide:
o Dedicated care managers who assure that enrollees
receive all needed medical, behavioral, and social services
from their assembled networks of treatment,
housing and social services
o in accordance with a single care management plan
o that is shared with all providers via an electronic
healthcare record
 HARPs
will have up to 1 year to enroll
members in health homes
30
15
3/11/2014
Core Attributes of Person-Centered
Health Homes
Mauer 2012






Access to Care: Be there when I need you.
Accountability: Take responsibility for making sure I
receive the best possible healthcare.
Comprehensive Whole-Person Care: Provide or help
me get the healthcare and services I need.
Continuity: Be my partner over time in caring for my
health.
Coordination and Integration: Help me navigate the
healthcare system to get the care I need in a safe and timely
way.
Person- and Family-Centered Care: Recognize that I
am the most important member of my care team and that I
am ultimately responsible for my overall health and wellness.
NYS Medicaid Redesign Response:
Managed Integrated BH & Medical Care
OASAS
Health and Recovery
Plan (HARP)
Health
Home
Team
= Physical and/or
behavioral health
care provider
STATE MEDICAID
AGENCY DOH
Health and
Recovery Plan
(HARP)
Payers
Health Home
Team: Provider
Network
OMH
Health and Recovery
Plan (HARP)
Health
Home
Team
Health
Home
Team
32
16
3/11/2014
Cultural Competence

The goal of cultural competence is to
create a health care system and
workforce that are capable of delivering
the highest care to every patient
regardless of race, ethnicity, gender,
culture and language proficiency
Critical Importance of Culturally
Competent Approaches
To address substantial racial/ethnic
disparities in healthcare
 Poor engagement of ‘minority’ groups has
lead to high percentages of costly:
avoidable use of:

◦ ERs, hospital and detox facilities
◦ Homeless shelters
◦ Jails and prisons
17
3/11/2014
Barriers to Engagement
Lack of culturally competent approaches
 Disparities within the workforce
 Reluctance by communities around
psychiatric diagnosis and treatment

◦
◦
◦
◦
Stigma
Hopelessness
Poverty
Chaos and disorganization in lifestyles for
some
Opportunities for Organizational
Cultural Competence Within MCOs
Establish CC outcome measures at the
state level for inclusion in MCO planning
 Inclusion of culturally relevant information
in Electronic Health Records
 Risk assessment based on quantitative and
qualitative cultural components, with
related performance metrics for each
group

18
3/11/2014
Opportunities for Organizational
Cultural Competence Within MCOs

Internal CC advisory committee with quarterly
input from community members and network
providers
◦ Link to community affairs division at plan level and
within OMH/OASAS
Internal CC plan that includes targets of staff
hiring and retention, outreach and member
engagement, member satisfaction, and review/
implementation of a specific CC budget
 Promote the use of culturally-relevant EBPs in
HH and provider networks

Opportunities for Provider-Level
Cultural Competence
New service approaches offer opportunities for
engagement and research related to CC methods in
care; not assuming that rehab-focused services are
CC.
 Culturally friendly service delivery should be
understood at MCO/HH level, and implemented
across service provision; new collaborations with
community health partners can strengthen CC, as
well as culturally relevant delivery locations.
 Community supports and resources should
accompany service delivery; this can occur at care
management level but should be encouraged during
service delivery to move forward process of
recovery.

19
3/11/2014
Opportunities for Provider-Level
Cultural Competence, continued


Implement measures that evaluate member
outreach, service satisfaction, and delivery
outcomes given CC measures.
Address member barriers with a blend of
socio-cultural and logistical adaptations:
◦ Blend improvements to linguistic and delivery
locations with training for staff members, and
reflect CC in personal health records;
◦ Trauma-informed care must intersect with
adaptations to 1915i or EBT services, inclusive of
specific intersections of cultural awareness
Expanded Understanding of Cultural
Intersections with Care Delivery
Systemic cultural implications transcend racial
and ethnic boundaries—there are cultures
within age groups, professions, perceptions of
class or institutional poverty levels, region
(including neighborhood within borough), and
migrant communities.
 Hiring professionals and peers from within the
served communities is important, but training,
outreach, and engagement must include
community awareness and inclusion given scope
of cultural intersections.

20
3/11/2014
Opportunities for Cultural
Competence in Health Homes
Important to isolate CC within the scope
of HH practice and come up with quality
measures that reflect CC metrics and
practices at the plan and provider level.
 Possible to create CC factors that are
tied to the overall success of the HH, and
may be useful when HHs enter into a
competitive relationship in a managed
care environment.

Opportunities for Cultural Competence in
Health Homes, continued





Outreach should include community leaders,
strategies beyond telephonic engagement
Conduct client and family cultural assessments,
and include consumer-valued persons in
assessment and plan-of-care process
Ensure communication competencies including in
the dissemination of promotional materials
Develop strategies for trust building and stigma
reduction relevant to target communities
Provide linkages to culturally valued community
supports, including peer support networks,
churches, and relevant out-of-network providers
21
3/11/2014
NKI Cultural Competency Assessment
Scale (CCAS) Organizational Level








Organizational commitment to CC
Collecting needs assessment data
Receiving community input
Infusing CC throughout an organization
Training staff
Making language accommodations
◦ Interpreters
◦ Bi-lingual Staff
◦ Key Forms, Service Descriptions, Educational Materials
Hiring and retention policies
Adapting and creating new services
Justification for Inclusion of Culturally
Competent Expectations in Managed Care

The business case:
◦ CC in MH bring added by potentially reducing costs
and improving care
◦ CC measures lead to better integrated care through
improved care coordination, information sharing, and
continued engagement
◦ New statewide goals within DSRIP to reduce
avoidable hospitalizations can be facilitated through a
CC approach in engaging difficult to reach
communities
44
22
3/11/2014
NYAPRS Advocacy Strategies for
Inclusion of Cultural Competence




Work with cross-agency redesign team to integrate
CC outcome measures; these can be measured by
percentage of cross-cultural enrollment,
engagement, and follow-up
Help MCOs translate outcome measures and
national, regional best practices into concrete
initiatives
Work through MRT process to build coalition
support and understanding of CC
Work with Health Home Learning Collaborative and
MRLTC to improve care management and provider
response
45
OMH on Cultural Competence
A culturally competent managed care delivery
system improves member satisfaction by
increasing communication, improves quality
and health outcomes through adherence to
treatment, and reduces health disparities.
Describe what your plan currently does, and proposes to
do, in regard to cultural competence, as the behavioral
health benefit moves into premium.
 Address the following areas. What you do now, what you
plan to modify to prepare for the behavioral health benefit?
 How do you assure access standards are equal across
cultural groups?

46
23
3/11/2014
OMH on Cultural Competence
 What
training will you provide regarding
cultural competence to your staff and
network partners?
 How do your hiring practices address
the cultural needs of your members?
 How does literature and website reflect
the cultural diversity of your members?
47
OMH on Cultural Competence
How do you address the range of languages
your members speak?
◦ In your call center?
◦ In your networks?
 How do your quality assurance protocols
evaluate your plan’s success in addressing
cultural diversity in the following areas?
◦ Data collection and metrics
◦ Satisfaction surveys
◦ Network monitoring
◦ Corrective action
48
24
3/11/2014
Managed Care Timeline
49
Questions?
[email protected] / [email protected]
25