Transcript Responsible Change to Achieve Easy Access, Better Quality

Partnering for Success:
Save Our Planet,
The 1915 (b)/(c) Medicaid Waiver
Save Our Wildlife!
&
DHHS Strategic Implementation Plan Update
NC School Community Health Alliance Conference
December 4, 2012
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“Responsible Change to Achieve
Easy Access, Better Quality and Personal Outcomes”
Presentation by: Kathy Nichols, DMA
Mabel McGlothlen, DMH
Priority of DHHS, DMA & DMHDDSAS
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Start Date:
July 1, 2010
o
Building success upon success
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Improving quality and effectiveness
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Increasing accountability for all stakeholders
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Contain Medicaid Cost
o
o
Expansion
Completion
Date:
July 1, 2013
Increasing consumer/family/stakeholder confidence in the
MH/DD/SA provider network
Priority tasks:
o
o
1915 b/c Waivers
Provider Quality
The Vision
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Overarching Goal:
To successfully provide
easily accessible, high quality,
cost effective MH/DD/SA services
and supports that result in person-centered
outcomes for individuals served.
Building success one step at a time.
2010
2011
2012
2013
Future
DHHS 1915 b/c Waiver Goals
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Start Date:
April 2009
1. Improve access to MH/DD/SAS Services.
2. Improve quality of MH/DD/SAS Services.
3. Improve outcomes for people receiving MH/DD/SAS
Services.
4. Improve access to primary care for people with mental
illness, developmental disabilities and substance abuse.
RFA
Selection Date:
July 1, 2010
5. Improve cost benefit of services.
6. Effectively manage all public resources assigned to the
MCOs.
DMHDDSAS Reform & DMA Waiver History
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History:
2001

2001 – State Plan 2001: Blueprint for Change (41 APs)

2003 – LMEs Local Business Plan submissions… PBH

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2010
2005 – Through DMA, CMS awarded PBH, the right to
administer and manage a State 1915 b/c waiver as a
pilot project for the delivery of publicly funded
MH/DD/SA services operating in Cabarrus, Davidson,
Rowan, Stanly, and Union Counties.
April 2009 – Legislative Report Medicaid Waivers for
LMEs S.L. 2008-0107 Section 10.15(y)
In May 2009 – The Secretary requested that DMH and
DMA develop a 1915 b/c Medicaid waiver amendment
for Statewide waiver expansion, replicating PBH’s waiver,
for submission to CMS by Dec. 15, 2009
First Round of Request For Applications (RFA’s)
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Start Date:

April 2010

RFA
Selection Date:
July 2010

SESSION 2009, SL-2010-31 / SB 897; Section 10.24

RFA Process, the State can select two waiver entities; PBH
cannot expand; complete a Legislative Report;

Legislative Report: an evaluation: I/DD consumers survey
and ICF-MR Facility Impact
RFA Applications received – April 2010
 Mecklenburg, Western Highland Network, Sandhills
Center and ECBH.
DHHS RFA Announcement Selection – July 2010
 Mecklenburg and Western Highland Network
Session Law 2011 – 264, House Bill 916
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Start Date:
July 1, 2011
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House Bill 916
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Expansion
Completion
Date:
July 1, 2013
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ECBH and SHC allowed to go forward Waiver
Implementation plans based upon original application
PBH allowed to expand /cancelling SB 897 (SB316)
New LME population requirements 300K – 2012 /
500K – 2013 (consistent with RFA requirements)
By October 1, 2011 submit a strategic plan
delineating specific strategies and agency
responsibilities for the achievement of statewide
expansion of the 1915 (b)/(c) Medicaid Waiver.
RFA Selection Announcement by August 2011
DHHS – January 2013 / July 2013 – Complete
unassigned LME Programs.
Second Round RFA
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Start Date:

July 1, 2011

Expansion
Completion
Date:
July 1, 2013
RFA Applications Submission – May 2011
 PBH Expansion Notice (A-C, Five County, OPC)
 CenterPoint; Durham Center (Johnston, Guilford,
Cumberland); Eastpointe (Beacon, SER); Pathways
(MHP, Crossroads); Smoky Mountain; Southeastern
Center (Onslow-Carteret); and Wake County
 July 26th - Successful Application Reviews: Eastpointe;
Pathways; and Smoky Mountain
RFA Applications resubmission / Final Selection
 Durham Center – July
 CenterPoint and Southeastern Center – November
Final LME-MCO Merger Map
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Local Management Entity - Managed Care Organizations (LME-MCOs)
and their Member Counties (Current and Proposed on January 1, 2013)
Central Region
Eastern Region
CenterPoint Human Services
Jan 2013
East Carolina Behavioral Health
Apr 2012
Western Region
Partners Behavioral Health Management
Jan 2013
Smoky Mountain Center
Jul 2012
Ashe
Alleghany
Surry
Stokes RockinghamCaswell Person
Northampton
Warren
Vance
Gates
Hertford
Camden
Currituck
Pasquotank
Perquimans
Chowan
Halifax
Granville
Orange
Guilford Alamance
Franklin
Bertie
Mitchell
Durham
Caldwell
Nash
Davie
Yancey
Alexander
Edgecombe
Madison
Iredell
Davidson
Wake
Martin Washington
Burke
Tyrrell
Chatham
Randolph
McDowell
Catawba
Wilson
Rowan
Buncombe
Pitt
Beaufort
Haywood
Johnston
Lincoln
Greene
Hyde
Lee
Swain
Rutherford
Cabarrus
Henderson
Montgomery
Graham
Harnett
Gaston
Jackson
Stanly
Wayne Lenoir
Polk
Moore
Craven
Cleveland
Transylvania
Mecklenburg
Cherokee
Macon
Cumberland
Pamlico
Clay
Richmond
Sampson
Jones
Union
Anson
Hoke
Duplin
Watauga
Avery
Wilkes
Yadkin
Forsyth
Western Highlands Network
Jan 2012
Onslow
Scotland
MeckLINK Behavioral Healthcare
Feb 2013
Cardinal Innovations Healthcare Solutions
(All counties as of Apr 2012)
Sandhills
Center Dec
2012/ Guilford
Apr 2013
Robeson
Bladen
Columbus
Brunswick
Eastpointe
Jan 2013
Pender
New
Hanover
Dare
Carteret
Alliance Behavioral Healthcare/
Johnston/ Cumberland
Jan 2013
CoastalCare
Feb 2013
For proposed LME-MCOs that have not yet merged, the lead LME name is shown first.
Sandhills Center and Guilford are scheduled to merge on January 1, 2013.
● Dates shown through July 2012 are actual Waiver start dates. Dates after July 2012 are
the planned Waiver start dates.
● Reflects plans and accomplishments as of October 12, 2012.
LME-MCO Implementation Time Line
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GOALS:
1. Improve access to
MH/DD/SAS Services.
IMPLEMENTATION / Start Date Time lines….

2. Improve quality of
MH/DD/SAS Services.
3. Improve outcomes for people
receiving MH/DD/SAS
Services.
4. Improve access to primary
care for people with mental
illness, developmental
disabilities and substance
abuse.

Phase I

PBH

WHN
- January 2012

ECBH
- April 2012
Phase II

Smoky Mountain -

SHC
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
- AC – Oct. 2011; 5 Cty – Jan. 2012; OPC – Apr. 2012
December 2012
Guilford County Merger January 1st / Waiver of GC: April 1st.
Phase III – Implementation completed by January / July 2013

Alliance (Durham/Wake) / CenterPoint / Eastpointe (BC/SER) /
Partners (PW/CR/MHP) / *Mecklenburg / *CoastalCare (SEC/ OC)

5. Improve cost benefit of
services.
6. Effectively manage all public
resources assigned to the
MCOs.
July 2012
* reflects potentially a February 1st start date.

DHHS – assigns unassigned catchment areas – January 2013

DHHS Process to be finalized by July 2013.
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POST IMPLEMENTATION January / July 2013….
What is a Medicaid Waiver
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Medicaid
Waiver - 101


DMA (Medicaid) gets a 1915b/c waiver from CMS
(Centers for Medicare & Medicaid)
The waivers allows DMA to let a managed care
company (LME) run the Medicaid program for
mh/sa/dd services in their counties.

Allows DMA to offer HCBS (habilitation)

“Mini Medicaid Program”
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DMA monitors the LME-MCOs to make sure that they
follow all Medicaid rules.
CMS monitors DMA
Medicaid Waiver Goals
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
Improved Quality of Care
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Increased Cost Benefit
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Predictable Medicaid Costs
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Combine the management of State/Medicaid Service Funds at the
Community Level
Increased consistency, efficiency and economies of scale in the management
of community services
Support the purchase and delivery of best practice services
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Ensure that services are managed and delivered within a quality
management framework
Empower the LME-MCO to build partnerships with consumers, providers and
community stakeholders with the goal of creating a more
responsive system of community care.
What does the LME-MCO do for Medicaid?
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Enroll & monitor providers (statewide)

Call Center—Customer Support, expansion of STR
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Make sure consumers with greatest need get connected to providers
and have treatment plans (Care Coordination)
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Authorize “medically necessary” services
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Pay for mh/sa/dd services
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Provide education about ALL Medicaid benefits to recipients &
consumers (website, mailings, seminars)
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Reviews, Medications Care Management, OAH Hearings (Due Process)
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Gap analysis/community development
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CCNC collaboration
Medicaid “Care Coordination for Special Health Care
Needs” vs. Targeted Case Management
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
Care Coordination (42 CFR 438.208(c))
 I/DD (eligible for Innovations)
 Innovations waiver recipient
 Adult SPMI & LOCUS score
 Child SED & CALOCUS score
 Substance Dependence & ASAM level
 Opioid Dependent & IV-use
 Dual Diagnosis & LOCUS/ASAM level
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Identify
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Assure Treatment Plan exists
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Assure access to all assessments & specialists
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Episodic & Time-limited
CCNC & LME-MCO Collaboration
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CCNC = NC Health Home
LME-MCO is vital partner that supports Health Home
Shared Care Management of recipients
 Identification, linkage to services
 Coordination of MH/SA/DD & physical health needs
Data exchange into Informatics
Collaboration on integrated care practices
Monthly-quarterly partnership meetings
Care Coordination = health promotion = cost savings
Provider Concerns in a 1915 b/c Waiver
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
Limited Provider Network

Care Coordination inside the MCO
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LME rate negotiation capacity (Note: higher rates can be paid to
address access concerns)

Expanded service authorization function

Loss of direct enrollment in State Medicaid Program (contract with LME)
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Loss of State level cost reporting/cost finding
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Inclusion in larger system of care (e.g. community ICF-MR facilities)
Note: Some concerns can be addressed in the DMA and DMHDDSAS
Waiver Contracts signed by the LME-MCO
What else does DMA require of the LME – MCO
?
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They must hire disability-specific specialists
 Psychiatrists
 Psychologists
 I/DD Qualified Professionals
 Licensed mental health professionals (LCSW, LPC)
 Licensed substance abuse professionals (LCAS)
Robust Quality Management Process
 Provider & consumer involvement
DMA, DMHDDSAS, and two external vendors monitor the LME-MCO —
monthly, quarterly, yearly (on all operations)
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EQRO
Annual Review
1915 b/c Waiver “At-Risk” Benefits
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They can develop their own Utilization Management (UM)
criteria, Level of Care (LOC), Length Of Stay (LOS)
They can do “care management”— have clinical discussions
with providers
Use the Treatment Authorization Request (TAR) but they can
ask for additional information
Limit their provider network (after initial offer of contract to all
Medicaid providers)
 Pay differential rates—for specialty care, for crisis services,
for performance; can use case rates or sub-capitation
1915 b/c Waiver “At-Risk” Benefits
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“ Extra Services ” : b3 Services

Projected savings from better management of care & network
 Inpt, ED use, LOS in residential treatment, pay for outcomes
 Supports Intensity Scale (SIS)*

Extra services that benefit the population
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PBH: robust array (mature network)
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New LME-MCOs
 Respite* (children, Innovations waitlist)
 Community Guide (Innovations waitlist)
 Peer Support Services (MH/SA consumers)
Waiver Supports Intensity Scale (SIS)
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Approved by CMS for use in NC
SIS used for planning purposes (AAIDD)
 Used to develop funding levels currently in the following
States: OR, CO, LA, GA, WA, RI, & 2 Canadian provinces;
 In process for development to use for purposes to
determine funding levels: NC, UT, MA, ME, ND
**CAP MR/DD services crosswalk to Innovations services = web
posting…
CCNC—NC Health Home
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
CCNC is the Health Home for NC Medicaid recipients.
CCNC is responsible for the following for patients with “chronic
conditions*”:
 Comprehensive care management
 Care coordination/health promotion
 Comprehensive transitional care
 Patient and family support
 Referrals to community and social support services
 Use of HIT to link services

*including serious/persistent mental illness and substance abuse disorders
CCNC—NC Health Home Behavioral
Health Initiatives
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
14 Psychiatrists in Regional Networks
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Teach PCPs to address MH/SA issues in primary care
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Teach PCPs to collaborate with behavioral health providers
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Use brief screenings
 Ex. Screening, Brief Intervention, and Referral to Treatment
(SBIRT)
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MDD education and treatment
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Atypical antipsychotic programs for children
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Training CCNC care managers and PCPs in Motivational
Interviewing
Health Homes and Specialty Behavioral
Health
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CCNC (Community Care of NC) will be NC’s Health Home Model with
the LME/MCO to address the behavioral health needs through
the 1915 b/c waiver
Much work has been done to interface the data sharing and to
clarify the roles/responsibilities of LME/MCOs and CCNC
Four Quadrant Care Management Model
 Determines who takes the lead in care management
 Quadrants 1 and 3 – CCNC/Primary Care take lead
 Quadrant 2 – LME/MCO/Behavioral Health take lead
 Quadrant 4 – flexible sharing of responsibilities
CCNC Four Quadrant Care Management Model
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Quadrant I:
Quadrant II:
 Low MH/DD/SA health
 High MH/DD/SA health
 Low physical health
complexity/risk
 Low physical health
complexity/risk
Quadrant III:
Quadrant IV:
 Low MH/DD/SA health
 High MH/DD/SA health
 High physical health
complexity/risk
High physical health
complexity/risk
CCNC Health Homes & LME - MCOs
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LME/MCOs provide care management for individuals with SPMI and
substance use “chronic conditions”
LME/MCOs formed a collaborative relationship with local CCNC
networks
LME/MCOs signed data-sharing agreements with the CCNC
Informatics Center
Waiver Strategic Plan Report
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


The Waiver Strategic Plan Report is an initial guide to
monitor LME/MCO waiver implementation and takes us
through the dates of January 2013.
The report is considered an initial plan that will evolve and
be modified over time, experience, and with LME and
stakeholder involvement.
The Department through DMH/DD/SAS and DMA will
monitor, evaluate and report the progress quarterly per
legislative requirements.
Web link to the report….
http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/
waiver1915b-cplan-final10-19-11.pdf
Waiver Strategic Introduction – Continued:
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GOALS:
1. Improve access to
MH/DD/SAS Services.
The Strategic Implementation Plan:

2. Improve quality of
MH/DD/SAS Services.
3. Improve outcomes for people
receiving MH/DD/SAS
Services.
4. Improve access to primary
care for people with mental
illness, developmental
disabilities and substance
abuse.
5. Improve cost benefit of
services.
6. Effectively manage all public
resources assigned to the
MCOs.


Is organized around a framework encompassing the
State’s vision for the Waiver initiative and goals.
Is based on an assessment of strengths and the
challenges that lie ahead.
Will provide a vehicle for active communication with all
stakeholders across the State and for coordinating
detailed implementation tasks among the Department,
DMA, DMH/DD/SAS, LMEs, providers and consumers,
and family members.
Pre-Implementation Plan Process for LMEs
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GOALS:

1. Improve access to
MH/DD/SAS Services.
2. Improve quality of
MH/DD/SAS Services.
3. Improve outcomes for people
receiving MH/DD/SAS
Services.
4. Improve access to primary
care for people with mental
illness, developmental
disabilities and substance
abuse.
5. Improve cost benefit of
services.
6. Effectively manage all public
resources assigned to the
MCOs.
PRE – Implementation Monitoring Phase of LME-MCOs
reporting out on their implementation activities

IMT’s (Intra-Departmental Monitoring Team)

Agenda: Report out of all of the LME-MCO function
areas of development…

Aggregate IMTs /// Think Tank IMTs

Two Readiness reviews State & Contract Agent

CMS Approval.

The DHHS Executive Monitoring Team (EMT) including
representatives from multiple stakeholder groups
provided review and feedback
Post-Implementation Process for LME-MCOs
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GOALS:

1. Improve access to
MH/DD/SAS Services.
2. Improve quality of
MH/DD/SAS Services.
POST - Implementation Phase IMT



EQRO – DMA vendor goes to the LME.
6 months of on-going monthly monitoring IMTs
Annual Reviews

3. Improve outcomes for people
receiving MH/DD/SAS
Services.


4. Improve access to primary
care for people with mental
illness, developmental
disabilities and substance
abuse.
5. Improve cost benefit of
services.
6. Effectively manage all public
resources assigned to the
MCOs.




Positive
Improvement
POC
Industry Standard Recommendations…. EBP Services
Feedback built into a plan of correction
Quarterly IMTs
EMT
Evaluation Process, Continued:
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The REAL Start
Date:
Jan 1, 2013
CQI Date: Ongoing !
Additional mechanisms to evaluate the Waiver
implementation process and ensure the quality of the
service system, include, but are not limited to:

External Quality Review (EQR)

Intra-departmental Monitoring Teams (IMTs)

Annual On-site Reviews

Performance Measures

Executive Management Team (EMT)

Global Continuous Quality Improvement

DMH/DD/SAS Quality Improvement Steering Committee
“Responsible Change to Achieve
Easy Access, Better Quality and Personal Outcomes”
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WAIVER GOALS:
1. Improve access to
MH/DD/SAS Services.
2. Improve quality of
MH/DD/SAS Services.
3. Improve outcomes for people
receiving MH/DD/SAS
Services.
4. Improve access to primary
care for people with mental
illness, developmental
disabilities and substance
abuse.
5. Improve cost benefit of
services.
6. Effectively manage all public
resources assigned to the
MCOs.
The LME-MCOs managing the 1915 b/c Waivers will
continue to evolve and be modified over time with
continued stakeholder involvement striving for quality
and improvement of the mh/dd/sas system.
Thank you…
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Questions / Thoughts / Comments….