“ responsible change to achieve easy access, better quality and personal outcomes”

1 “Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes”

Presentation by: Kathy Nichols, DMA Mabel McGlothlen, DMH

Save Our Planet,Save Our Wildlife!

Partnering for Success:The 1915 (b)/(c) Medicaid Waiver

& DHHS Strategic Implementation

Plan Update

NC School Community Health Alliance Conference

December 4, 2012

2

Priority of DHHS, DMA & DMHDDSASStart Date:July 1, 2010

Expansion Completion

Date:July 1, 2013

o Building success upon successo Improving quality and effectivenesso Increasing accountability for all stakeholderso Contain Medicaid Costo Increasing consumer/family/stakeholder

confidence in the MH/DD/SA provider networko Priority tasks:

o 1915 b/c Waiverso Provider Quality

3

The Vision

1915 B/C Medicaid

Waiver

The State

CAP-MR/DD

WaiverOverarching Goal:

To successfully provide easily accessible, high quality,

cost effective MH/DD/SA servicesand supports that result in person-centered outcomes for

individuals served.

Building success one step at a time.

2010 20122011 2013 Future

Provider Quality

4

DHHS 1915 b/c Waiver Goals

Start Date:April 2009

RFA Selection

Date:July 1, 2010

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.

5

DMHDDSAS Reform & DMA Waiver History

History:2001

2010

2001 – State Plan 2001: Blueprint for Change (41 APs)

2003 – LMEs Local Business Plan submissions… PBH 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

6

First Round of Request For Applications (RFA’s)

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

7

Session Law 2011 – 264, House Bill 916

Start Date:

July 1, 2011


Date:

July 1, 2013

House Bill 916 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.

8

Second Round RFA

Start Date:

July 1, 2011


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

9

Final LME-MCO Merger MapLocal Management Entity - Managed Care Organizations (LME-MCOs)

and their Member Counties (Current and Proposed on January 1, 2013)

Anson

Ashe

Avery

Beaufort

Bertie

Bladen

Brunswick

Burke

Cabarrus

Caldwell

Carteret

Catawba Chatham

CherokeeClay

Cleveland

Columbus

Craven

Currituck

Forsyth

Gates

Graham

Granville Halifax

HarnettHenderson

Hertford

Jackson

Jones

LeeLincoln

Macon

Madison

MontgomeryMoore

Nash

Northampton

Onslow

Pamlico

Pender

Pitt

Polk

Robeson

Rockingham

Rowan

Rutherford

StokesSurry

Swain

Union

Vance

Wake

Warren

Watauga Wilkes

Wilson

Yancey

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.

Orange

Transylvania

Person

Western Region Central Region Eastern Region

Cumberland

Scotland

Haywood

NewHanover

Durham

Alleghany

Alamance

Iredell

Johnston

DuplinSampson

Wayne Lenoir

Dare

Hyde

Martin TyrrellWashington

Camden

PerquimansPasquotank

Greene

Smoky Mountain Center Jul 2012

AlexanderMitchell

Gaston

Buncombe

CenterPoint Human Services Jan 2013

Caswell

Chowan

Edgecombe

Western Highlands NetworkJan 2012

McDowell

Alliance Behavioral Healthcare/Johnston/ Cumberland

Jan 2013

CoastalCareFeb 2013

Guilford

Randolph

East Carolina Behavioral Health Apr 2012

EastpointeJan 2013

MeckLINK Behavioral HealthcareFeb 2013

Cardinal Innovations Healthcare Solutions(All counties as of Apr 2012)

Partners Behavioral Health Management Jan 2013

Stanly

DavieFranklin

HokeRichmond

Mecklenburg

Yadkin

Davidson

Sandhills Center Dec

2012/ GuilfordApr 2013

10

LME-MCO Implementation Time Line

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.

IMPLEMENTATION / Start Date Time lines…. Phase I

PBH - AC – Oct. 2011; 5 Cty – Jan. 2012; OPC – Apr. 2012 WHN - January 2012 ECBH - April 2012

Phase II Smoky Mountain - July 2012 SHC - 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)

* reflects potentially a February 1st start date. DHHS – assigns unassigned catchment areas – January 2013 DHHS Process to be finalized by July 2013. POST IMPLEMENTATION January / July 2013….

11

What is a Medicaid Waiver

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” DMA monitors the LME-MCOs to make

sure that they follow all Medicaid rules.

CMS monitors DMA

12

Medicaid Waiver Goals Improved Quality of Care Increased Cost Benefit Predictable Medicaid Costs Combine the management of State/Medicaid Service Funds

at the Community Level Increased consistency, efficiency and economies of scale in

the management of community servicesSupport the purchase and delivery of best practice services 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.

13

What does the LME-MCO do for Medicaid?

Enroll & monitor providers (statewide) Call Center—Customer Support, expansion of STR Make sure consumers with greatest need get connected

to 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 Care Management, OAH Hearings

(Due Process) Gap analysis/community development CCNC collaboration

14

Medicaid “Care Coordination for Special Health Care Needs” vs.

Targeted Case Management

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

Identify Assure Treatment Plan exists Assure access to all assessments & specialists Episodic & Time-limited

15

CCNC & LME-MCO Collaboration 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

16

Provider Concerns in a 1915 b/c Waiver Limited Provider Network Care Coordination inside the MCO 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) Loss of State level cost reporting/cost finding 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

17

What else does DMA require of the LME – MCO ?

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)

EQRO Annual Review

18

1915 b/c Waiver “At-Risk” Benefits

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

19

1915 b/c Waiver “At-Risk” Benefits

“ 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 PBH: robust array (mature network) New LME-MCOs

Respite* (children, Innovations waitlist) Community Guide (Innovations waitlist) Peer Support Services (MH/SA consumers)

20

Waiver Supports Intensity Scale (SIS)

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…

21

CCNC—NC Health Home 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

22

CCNC—NC Health Home Behavioral Health Initiatives

14 Psychiatrists in Regional Networks Teach PCPs to address MH/SA issues in primary care Teach PCPs to collaborate with behavioral health

providers Use brief screenings

Ex. Screening, Brief Intervention, and Referral to Treatment (SBIRT)

MDD education and treatment Atypical antipsychotic programs for children Training CCNC care managers and PCPs in

Motivational Interviewing

23

Health Homes and Specialty Behavioral Health

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

24

CCNC Four Quadrant Care Management Model

Quadrant I:

Low MH/DD/SA health

Low physical health complexity/risk

Quadrant II:

High MH/DD/SA health

Low physical health complexity/risk

Quadrant III:

Low MH/DD/SA health

High physical health complexity/risk

Quadrant IV:

High MH/DD/SA health

High physical health complexity/risk

25

CCNC Health Homes & LME - MCOs

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

26

Waiver Strategic Plan Report

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

http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/waiver1915b-cplan-final10-19-11.pdf

http://www.ncdhhs.gov/mhddsas/providers/1915bcWaiver/waiver1915b-cplan-final10-19-11.pdf

27

Waiver Strategic Introduction – Continued:


MH/DD/SAS Services.






The Strategic Implementation Plan:

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.

28

Pre-Implementation Plan Process for LMEs


MH/DD/SAS Services.






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

29

Post-Implementation Process for LME-MCOs


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

Positive Improvement POC Industry Standard Recommendations…. EBP

Services Feedback built into a plan of correction Quarterly IMTs EMT

30

Evaluation Process, Continued:

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

The REAL Start Date:Jan 1, 2013

CQI Date: On-going !

31

“Responsible Change to Achieve Easy Access, Better Quality and Personal Outcomes”

Plan

ActEvaluat

e

Improve

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.

WAIVER GOALS:1. Improve access to

MH/DD/SAS Services.






32

Thank you…

Plan

ActEvaluat

e

Improve

Questions / Thoughts / Comments….

“ responsible change to achieve easy access, better quality and personal outcomes”

Documents