(As of April 2013)
At a Glance
- A consolidated health purchasing authority, the Oregon Health Authority, houses both Medicaid and behavioral health services; the health authority’s Division of Medical Assistance Program is responsible for Medicaid behavioral health benefits.
- The authority’s Addictions and Mental Health Division maintains a statewide, coordinated Children’s Mental Health System, including a wraparound initiative for children.
- Managed care organizations support a package of community-based behavioral health benefits for children, which are provided through a county-based system of Community Mental Health Programs.
- The state has transitioned to the use of Coordinated Care Organizations that will manage both physical and behavioral health benefits for Medicaid beneficiaries.
Oregon has worked to create a comprehensive mental health system for children. The Oregon Health Authority (OHA) oversees the Medicaid children’s benefit (including the Early and Periodic, Screening Diagnostic, and Treatment benefit or EPSDT) and other services provided under the state’s Medicaid program, the Oregon Health Plan. The state relies on managed care organizations for Medicaid enrollees, including children. The OHA’s Division of Medical Assistance Programs (the state’s Medicaid agency) contracts with Coordinated Care Organizations (CCOs) to provide health services, including behavioral health, to adults and children as part of the Oregon Health Plan. The CCOs are required to make health care services available to Medicaid enrollees through a contracted network of private and county-based providers. The state also has a small primary care case management program (fee-for-service) in which children can voluntarily enroll.
OHA reviews and analyzes the performance of CCOs by reviewing a detailed set of health outcomes for adults and children. A series of Children’s Mental Health Dashboards record statistics including the number of Oregon Health Plan-enrolled children receiving mental health services, the percentage of those children receiving community-based services, and the percentage of capitated funds that CCOs bill for 0-17 year old members. The CCOs operate under a fixed global budget and phase in incentives for quality over time.
Coordination and Collaboration
Oregon benefits from a consolidated purchasing authority, the OHA, which was created in 2009. The OHA—working through its Addictions and Mental Health Division—is responsible for collaborating with other child-serving agencies to maintain a Children’s Mental Health System. It supports a “statewide comprehensive, coordinated, culturally competent, child centered, family driven continuum of care for children with serious emotional disorders and their families” in collaboration with county-based Community Mental Health Programs and CCOs.
An Addictions and Mental Health Planning and Advisory Council advises the OHA’s Addictions and Mental Health Division on policies and programs. A subcommittee of this group, the Children’s System Advisory Committee, focuses on policy for children and adolescents. This group draws together representatives of child welfare, education, juvenile justice, adolescent and drug treatment agencies, developmental disabilities and other child-serving agencies.
The state’s Assuring Better Child Development (ABCD) initiative to improve developmental and behavioral health screening for young children has worked in collaboration with the Oregon Pediatric Society’s Oregon START project to teach pediatric primary care physicians how to identify and manage behavioral health issues.
Oregon has also implemented a statewide Children’s Wraparound Initiative using Medicaid and general funds. The initiative aims to build a coordinated system of services for children with complex behavioral health needs and their families. In its initial phase, it is aimed at children in the custody of the state’s Department of Human Services and children with behavioral health conditions severe enough to warrant direct entry into the service system at a high level of care and is available in limited geographic areas. OHA is looking to expand the availability of these services.
Screening, Assessment and Referrals
As part of its ABCD initiative, Oregon worked to improve screening practices among pediatric primary care providers to increase identification of young children with developmental, behavioral, and/or psychosocial delays. The state operates a website that provides links for providers to the Ages and Stages Questionnaire, the Parent’s Evaluation of Developmental Status tool, the Bright Futures Pediatric Intake Form, a Point of Care Screening Tool from the American Academy of Family Physicians, and the Patient Health Questionnaire – 2 and 9. Additional tools for providers and referral forms have been compiled on a Child Health Provider Toolkit.
In 2011, Oregon governor convened an Early Learning Design Team to promote kindergarten readiness for all children in the state. The team’s Health Matters Screening Tools Workgroup released a report in September 2012 that included recommendations for behavioral/psychosocial health instruments. The workgroup recommended the Modified Checklist for Autism in Toddlers (M-CHAT) and the Ages and Stages Questionnaire – Social/Emotion (ASQ-SE).
In June 2011, the Oregon Department of Human Services released a manual for an Oregon version of the Child and Adolescents Needs and Strengths (CANS) comprehensive screening tool. The tool is aimed at children ages 6 through 20 and explores several facets of mental health, including child risk factors, traumatic stress symptoms, and child behavior/emotional needs. The workgroup also recommended Screening, Brief Intervention & Referral to Treatment (SBIRT) and the Patient Health Questionnaire-9.
State regulations reiterate the components of the Medicaid children’s benefit and specify that if mental health or substance abuse conditions are discovered during a primary care screening, physicians may refer children to the AMH for further diagnosis and treatment; however, the regulations do not require standardized behavioral health screening instruments. Oregon’s Medicaid fee schedule allows provider to bill the 96110 code for developmental screening, as well as the 96111 code for more extended developmental testing. The AMH also publishes lists of Medicaid procedure codes for mental health services and chemical dependency services, including diagnostic examinations and assessments.
CCO contracts require the use of the Child and Adolescent Service Intensity Instrument (CASII) to determine if Integrated Service Array supports (described below) are appropriate for children age 6 and older. The AMH offers providers a manual for the CASII, as well as the Early Childhood Service Intensity Instrument, on its website.
Oregon’s Department of Human Services has also produced standardized referral forms for use in the Medicaid children’s benefit. The forms allow primary care providers to indicate if the referral is for mental health or alcohol and drug use and requires the referral provider to provide a mental health/alcohol and drug contact person.
CCOs in Oregon are required to contract with Community Mental Health Programs (CMHPs), which provide services to persons with mental or emotional disorders and developmental disabilities. The CMHPs are often county mental health departments and are responsible for providing a range of Integrated Services and Supports for behavioral health, including services for children. The rules for these services are currently undergoing revisions to clarify and simply them. The CMHPs provide outpatient mental health services to children. This includes a variety of services, including crisis services, therapy and other psychiatric services, case management, and skills training. CCOs are required to establish working relationships with local mental health authorities and CMHPs.
Oregon offers Children’s Intensive Community-Based Treatment and Support Services (ICTS) through its Community Mental Health Programs. These services are a specialized set of in-home and community-based supports and mental health treatment services for children with serious behavioral disorders. They include: crisis prevention and intervention; care coordination; case management; individual, group and family therapy; psychiatric services; skills training; family support; respite care; and team-driven service coordination planning. These services can be delivered in a variety of settings, ranging from clinics or facilities to the child’s home to the school. ICTS includes care coordination and linkages to appropriate social services.
Children also have access to Intensive Treatment Services for Children, which includes Children’s Psychiatric Residential Treatment Services and Psychiatric Day Treatment Services. CCOs complete prior approval for enrolled children, while a third-party review organization is responsible for prior approval for children not enrolled in managed care.
CCOs are required to combine these services into an Integrated Service Array—intensive, individualized home and community-based services—to enrolled children and adolescents. The ISA integrates inpatient, psychiatric residential and Psychiatric Day Treatment services with the goal of minimizing institutional care and providing services in the community. The CCOs are responsible for promoting collaboration among mental health, child welfare, juvenile justice, education, and other community partners in establishing ISA services for children with serious behavioral health issues.
CCOs retain responsibility for children receiving any behavioral rehabilitation services outside the service area of the CCO in which they are enrolled unless the child is served through the Oregon Youth Authority; the CCOs must still make health services available to the child in the areas where the services are provided, and they must authorize and pay for the services.
CCOs are able to participate in the System of Care/Wraparound initiative for children eligible under the initial phase of the program. The state has collected data showing that children who receive wraparound services through the state’s System of Care experience reductions in the use of prescribed psychotropic medications and the type of prescribing provider for those children still taking medication shifts from psychiatrists to primary care physicians.
The authors wish to thank the many state officials and stakeholders who contributed to and reviewed the information in this document.
This document was prepared by NASHP for the Centers for Medicare & Medicaid Services (CMS) under a contract to NORC at the University of Chicago. It does not reflect the views of CMS.