Transcript Larson - CCO Oregon

Oregon Conference: Transforming
Care 2013
Tara Larson
Behavioral Health and Primary Care Integration
in North Carolina
January 8, 2013
Objectives
Outline several efforts to support the behavioral health
needs of the Medicaid population in North Carolina
through integration between Community Care of NC and
the behavioral health Managed Care Organizations.
Describe the complex medical/residential program.
Describe the A+KIDS antipsychotic safety registry in North
Carolina.
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Causes of Health Disparities in
Behavioral Health
 Medications (though problems evident BEFORE antipsychotics
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where available)
High rates of smoking, lack of weight management/nutrition,
and physical inactivity
Lack of access to/utilization of preventive community
healthcare, including health promotion services and resources
Poverty
Social isolation
Separation of health and mental health into separate systems
at the federal, state and local level with lack of coordinated
infrastructure, policy, planning, quality improvement
strategies, regulation or reimbursement
Parks,J, Radke,A, Mazade,N, and Mauer,B NASMHPD 16 th Technical Report : Measurement of Health Status for People with Serious Mental Illness. October
16, 2008.
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What is the Behavioral Health Initiative?
 Increase the use of evidence based treatment guidelines for
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behavioral health including depression, substance abuse, and
ADHD
Increase the number of co-located providers
Decrease the re-hospitalization rate for primary psychiatric
admissions
Increase access to preventive health care to people with
mh/dd/sa
Increase coordination of the care for people with mh/dd/sa
through case consultations, data mining, designation of lead
coordination
Decrease out of state placements for people with mh/dd/sa
and complex medical needs
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Why the Behavioral Health
Initiative?
CHCS Center for Health Care Strategies, Inc., Dec 2010
Clarifying Multi-morbidity Patterns to Improve Targeting and
Delivery of Clinical Services for Medicaid Populations
 The analysis confirms the overwhelming pervasiveness of physical
and behavioral health co-morbidity among Medicaid’s highest-cost
beneficiaries.
 Reinforcing earlier analyses, the findings demonstrate that most
beneficiaries with the highest hospitalization rates and costs have
not one condition, but many. Based upon Medicaid paid claims,
50% of all ED or inpatient admissions had mh/sa/dd diagnosis.
 Mental illness is nearly universal among the highest-cost, most
frequently hospitalized beneficiaries, and similarly, the presence of
mental illness and/or drug and alcohol disorders is associated with
substantially higher per capita costs and hospitalization rates.
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Community Care of NC (CCNC): “How it
works”
 Primary care medical home available to 1.2 million individuals in
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all 100 counties.
Provides 4,500 local primary care physicians( 94% of all NC
PCPs) with resources to better manage Medicaid population
Links local community providers (health systems, hospitals,
health departments and other community providers) to primary
care physicians , including mental health providers
Every network provides local care managers (600), pharmacists
(50+), psychiatrists (14+) and medical directors (20) to improve
local health care delivery
Coordinates behavioral health care through the behavioral health
MCO/LMEs
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Eligibility and Enrollment in Health
Homes
 Eligibility for Community Care of North Carolina
enrollment includes all categorically-eligible Medicaid
recipients including dually eligible individuals and persons
enrolled in 1915b/c mh/dd/sa waivers.
 Enrollment in the Health Homes program is opt out
through enrollment in CCNC.
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Population Management Components
for CCNC
Outreach / Education / Enrollment / Communication
Screening / Assessment / Care Plan
Risk Stratification / Identify Target Population
Patient Centered Medical Home – Evidence-based best
practices and team based care
 Targeted Disease and Care Management Interventions
and Best Practices
 Pharmacy Management, Medication Reconciliation
 Behavioral Health Integration
 Transitional Care
 Self Management of Chronic Conditions
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Community Care Networks
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Each CCNC network has:
 Clinical Director
 A physician who is well known in the community
 Works with network physicians to build compliance with care
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improvement objectives
 Provides oversight for quality improvement in practices
 Serves on the Sate Clinical Directors Committee
Network Director who manages daily operations
Care Managers to help coordinate services for enrollees/practices
PharmD to assist with Med management of high cost patients
Psychiatrist to assist in mental health integration
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Current State-wide Disease
and Care Management Initiatives
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Asthma (1998 – 1st Initiative)
Diabetes (began in 2000)
Dental Screening and Fluoride Varnish (piloted for the state in 2000)
Pharmacy Management
 Prescription Advantage List (PAL) - 2003
 Nursing Home Poly-pharmacy (piloted for the state 2002 - 2003)
 Pharmacy Home (2007)
 E-prescribing (2008)
 Medication Reconciliation (July 2009)
 Emergency Department Utilization Management (began with Pediatrics 2004 / Adults 2006 )
 Case Management of High Cost-High Risk (2004 in concert with rollout of
initiatives)
 Congestive Heart Failure (pilot 2005; roll-out 2007)
 Chronic Care Program – including Aged, Blind and Disabled
 Pilot in 9 networks 2005 – 2007
 Began statewide implementation 2008 - 2009
 Behavioral Health Integration (began fall 2010)
 Palliative Care (began fall 2010)
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1915 B/C Behavioral Health Waiver
 Operated
through 11 “quazi
governmental
1915
B/C Behavioral
Health
Waiver entities”
referred to as Local Management Entities (LMEs)
 Began in 5 counties in 2005 – will be statewide (100
counties) by June 30, 2013. By February 1, 99 counties
will be live.
 Fully Capitated, at risk for all mh/dd/sa services including
ED visits, inpatient, ICF-MR, outpatient, enhanced
mh/dd/sa services. Pharmacy is carved out. Some codes
in primary care are “unmanaged” for med management
and basic services
 To encourage one stop service delivery
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Proposed Local Management Entity - Managed Care Organizations (LME-MCOs)
and their Member Counties - by July 1, 2013
Central Region
Eastern Region
CenterPoint Human Services
Jan 2013
East Carolina Behavioral Health
Apr 2012
Western Region
Smoky Mountain Center
Jul 2012
Alleghany
Ashe
Watauga Wilkes
Mitchell
Madison
Yancey
Avery
Caldwell
Burke
Surry
Yadkin
Stokes
Forsyth
Person
Rockingham
Caswell
Northampton
Vance
Granville
Orange
Guilford Alamance
Durham
Davie
Alexander
Iredell
Davidson
Randolph
Catawba
Rowan
Chatham
Warren
Camden
Currituck
Pasquotank
Perquimans
Chowan
Gates
Hertford
Halifax
Franklin
Bertie
Nash
Wake
Edgecombe
Washington
Tyrrell
Martin
Wilson
Buncombe McDowell
Beaufort
Pitt
Haywood
Johnston
Lincoln
Greene
Lee
Swain
Rutherford
Cabarrus
Henderson
Montgomery
Graham
Harnett
Gaston
Jackson
Wayne Lenoir
Polk
Stanly
Moore
Craven
Cleveland
Transylvania
Mecklenburg
Cherokee
Macon
Cumberland
Pamlico
Clay
Richmond
Sampson
Jones
Union
Anson
Hoke
Duplin
Western Highlands Network
Jan 2012
Mecklenburg
Feb 2013
Partners Behavioral Health Management
(Pathways/ MH Partners/ Crossroads)
Jan 2013
Onslow
Scotland
Robeson
# Sandhills
Center/
Guilford
Dec 2012
Bladen
Columbus
Pender
New
Hanover
Dare
Hyde
Carteret
Durham/ Wake/
Johnston/ Cumberland
Jan 2013
Brunswick
PBH/ Alamance Caswell Oct 2011/
Five County Jan 2012/
OPC Apr 2012
Eastpointe/
Southeastern Regional/
Beacon Center
Jan 2013
Coastal Care System
(Southeastern Center/ OCBHS)
Jan 2013
Unless otherwise indicated, the LME name is the county name(s).
The lead LME name for the proposed LME-MCO is shown first.
Dates shown are the planned Waiver start dates.
Reflects plans as of February 9, 2012.
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1915b/c Waiver Goals
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Improved Quality of Care
Increased Cost Benefit
Predictable Medicaid Costs (2009 $22.57 per person, 2012$ 20.88)
Combine the management of State/Medicaid Service Funds at the
Community Level
Support the purchase and delivery of best practice services
Ensure that services are managed and delivered within a quality
management framework
Empower the LME/MCOs to build partnerships with consumers,
providers and community stakeholders with the goal of creating a
more responsive system of community care.
Increased consistency and economies of scale in the management
of community services
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What does the MCO/LME do for Medicaid?
 Enroll & monitor providers (statewide)
 Call Center—Customer Support
 Make sure consumers with greatest need get connected to
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providers and have treatment plans (Care Coordination)
Authorize “medically necessary” services
Pay for mh/sa/dd services
Provide education about ALL Medicaid benefits to recipients &
consumers (website, mailings, seminars)
Reviews, Medications, Hearings (Due Process)
Gap analysis/community development
CCNC collaboration
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Health Homes & Local Management
Entities/Managed Care Organizations
 CCNC (Community Care of NC) is 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
(informatics chart attached)
 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
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Four Quadrant Care
Management Model
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
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Health Homes & Local Management Entities/Managed
Care Organizations Continued . . .
 Shared Care Management of recipients
 Identification, linkage to services
 Coordination of MH/SA/DD & physical health needs
 Data exchange into Informatics
 LME/MCOs signed data-sharing agreements with the CCNC
Informatics Center
 Collaboration on integrated care practices
 Monthly-quarterly partnership meetings
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Integrated Care Toolkit
 In August 2011 an MH/DD/SA Integrated Care Toolkit was published to
assist MH/DD/SA providers in collaborating with CCNC and primary care
 Among other items, the toolkit includes:
 A flowchart to determine if an individual has a CCNC health home or
primary care provider
 A detailed description of the Four Quadrant Care Management Model
Responsibilities
 More information on the toolkit can be found in the August 2011
Medicaid Bulletin –
http://www.ncdhhs.gov/dma/bulletin/0811bulletin.html#car
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Managing Complex Cases
 Most recent initiative to integrate medical and behavioral healthcare
 NC has historically had to place children out of state who have complex
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medical and mh issues (such as brittle diabetic and bi-polar disorder)
Team formed with major regional hospital and medical school, specialty
physicians, CCNC network, LME/MCO, private providers offering
behavioral health residential care (in-home, therapeutic family living
and PRTF)
Team follows child
Single payment made for cost of total care (hospital, outpatient) –
bundled payment
Lead entity will pay all components providing care
Incentive payments will be made for meeting outcomes
Has been piloted through state dollars - will be Medicaid funded
beginning February 1, 2013 through EPSDT
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Initial Experience and Findings from a State Medication
Safety Registry
Psychoactive Medication Use in
Vulnerable Population Concerns
 Disproportionate use of psychoactive medications in
foster populations
 Possibly over-reliance on pharmacotherapy to address
behavioral concerns
 Psychoactive medication polypharmacy without clear
evidence basis
 Off-label use and limited short-term efficacy data or longterm adverse effect studies (off-label use may be an
appropriate practice in many cases)
 Lack of monitoring and coordination of care
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Foster Population in NCter
 80% are enrolled in CCNC PCMH (increase from 31% in
October, 2011)
 No clinically meaningful differences in Medicaid nonfosters and fosters in physical health indicators (asthma,
diabetes, etc)
 Marked differences in behavioral health indicator
prevalence
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Foster Population in NC
 Foster recipients 3X more likely to have a mental health
diagnosis (49% versus 13%)
 More likely to have an intellectual disability (13% versus
5%)
 More likely to have PTSD (8.5% versus 0.5%)
 More likely to have depression (6% compared to 1%)
 More likely to have bipolar d/o (3.6% versus 0.3%)
 Differences were insignificant for schizophrenia and other
psychoses
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Foster Population in NC
 Foster recipients had more OP visits, spent more on Rxs,
more on mental health treatment, more on inpatient and
ED visits and cost significantly more overall than nonfoster Medicare children/adolescents ($9,040 versus
$1,864 annually)
 Foster children enrolled in a CCNC PCMH cost less than
non-enrolled similar ($8,333 compared to $9,040 annual
mean cost/patient)
 This cost difference underscores the effort to get fosters
enrolled in PCMH
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NC Response: A+KIDS
 What
 Web-based safety registry system with fax option
 Clinical data entry at point of care by prescriber
 Automated Authorization at time of submission
Provider participation is only requirement
 Use of “Over-rides”
 No one should go without medication regardless of prescriber
participation
 Who
 All Medicaid Funded Youth 0-17
 Any antipsychotic Rx, New or Refill
 All Medicaid prescribers regardless of discipline
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NC Response: A+KIDS
 How
 Community Care North Carolina Network Infrastructure
 All Medicaid prescribers regardless of discipline or area of
practice were registered
 Phased introduction (0-12, 12-17, NC Healthchoice -SCHIP)
 Endorsement from advocacy and stakeholder groups
 Close Partnership with web development firm
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Infina Connect, LLC
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A+KIDS Initial Findings
Provider Participation
 From April 2011-August 21, 2012
 1241 prescribers with at least 1 authorization from the
registry
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1522 registered providers have not attempted to authorize a Rx
 29,691 total authorizations
 15,194 total patients
 1842 foster children in the registry
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A+KIDS Initial Findings
Resource Utilization Features
 Meds- 35% risperidone, 25% aripiprazole, 11%
quetiapine
 74% of A+KIDS patients are reported to be in some form
of psychotherapy
 Top 5% of prescribers account for 40% of authorizations
 2 prescribers account for 4% of all authorizations
 Top 25% of prescribers account for 81% of authorizations
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A+KIDS Initial Findings
Participation
Participating Prescriber Types After 6 Months of A+KIDS*
Developmental Pediatrician
Psychiatric Nurse Practioner
Non-Psychiatrist MD/DO
20%
Psychiatric Physicians Assistant
Psychiatrist MD/DO
Non-Psychiatrist MD/DO
Psychiatrist MD/DO
61%
Non-Psychiatrist MD/DO(but patient also
has a Psychiatrist)
Unknown
Developmental Pediatrician
2%
Psychiatric NP
3%
Psychiatric PA
1%
* Ages 0-12 Only
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A+KIDS Initial Findings
Clinical Features
25.0%
20.0%
Primary Dx Cited in
A+KIDS Registry- First Year*
15.0%
10.0%
*Ages 0-17
5.0%
0.0%
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A+KIDS Initial Findings
Clinical Features
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A+KIDS Initial Findings
Clinical Features-Body Mass Index
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A+KIDS Initial Findings
Clinical Features-Body Mass Index
Early Informal Comparisons, Adolescents
Source
NC A+KIDS, 2011-2012,
(Ages 13-17)
Prevalence Overweight*
(%)
Prevalence Obese**
(%)
19.6
30.6
North Carolina, 2009
(Ages 10-17)
CHAMP, BRFSS
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North Carolina, 2007-2008
(Ages 13-16)
Medicaid Enrollees*
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*Lazorick S, Peaker B, Perrin EM, Schmid D, Pennington T, Yow A, DuBard CA. Prevention and treatment of childhood obesity: care
received by a state Medicaid population. Clin Pediatric (Phila). 2011 Sep;50(9):816-26.
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A+KIDS Initial Findings
Prescribing Trends
Antipsychotic Fills Per Day Per 1000 Enrollees
Ages 13-17
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Next Steps with Foster Care Population
 Ongoing efforts to align foster population with
LME/MCO-CCNC
 Shared definition of population across all state agencies
 Improved descriptive statistics which characterize the
population healthcare resource utilization and risk factors
 Task force at state agency level to address development
of programs to support needs of this at risk population
 Case and provider profiling to identify specific follow-up
educational and/or consultative needs
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Questions?
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