Government Eliminates Waiver Requirement for Doctors Prescribing the Addiction Treatment Medication Buprenorphine
/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Jodi Manz and Kitty PuringtonUnder new US Department of Health and Human Services practice guidelines, physicians will no longer have to go through the cumbersome process of obtaining a federal waiver to prescribe the opioid use disorder (OUD) treatment buprenorphine to patients.
Eliminating the Drug and Alcohol Enforcement (DEA) waiver regulation requirement – long viewed as a significant hurdle to increasing access to OUD treatment medications – is expected to help promote the use of medications for OUD across a range of settings. Providers and policymakers have described the waiver process as antiquated and burdensome, hindering their ability to adequately address the ever-burgeoning opioid crisis.
This change was made under the Secretary’s authority to issue practice guidelines and exemptions to the regulatory requirements for buprenorphine prescribing. It does not change existing federal law, though this may signal that such legal change is on the horizon.
A bill introduced in 2019 by US Rep. Paul Tonko of New York to remove the waiver requirement language for all eligible prescribers remains alive in the House of Representatives, awaiting action. The incoming Biden Administration could swiftly retract this new guidance, but given the momentum toward removing barriers to OUD treatment, it is not expected to be repealed. The new administration is more likely, in alignment the campaign’s opioid epidemic plan’s emphasis on access to treatment, to codify such an expansion in providers’ ability to treat.
Before the waiver was eliminated, doctors had to:
Complete eight hours of training and complete an application to the Substance Abuse and Mental Health Services Administration.
Once granted a waiver, they could prescribe to a maximum of 30 patients for the first year.
After a year, they could submit another application to increase their patients to 100, and eventually serve up to 275 patients.
Providers have described the waiver process as antiquated and that ability to prescribe to only 30 people in the first year hindered their ability to adequately address the opioid crisis.
Because the waiver requirement was previously required for physicians in order to prescribe the medication component of OUD treatment services according to federal law, states similarly imposed this requirement in their own approaches and may need to take steps to re-align policy with the new federal guideline:
- States that integrated buprenorphine prescribing practices into their licensing regulations for prescribers may need to amend regulations to reflect changes to physician requirements. In some states, such regulations are also intended to promote prescribing safety, requiring that providers document connections to counseling and other supports, an effort designed to minimize potential diversion of buprenorphine. States could take steps to maintain – or even strengthen – these requirements, as diverted buprenorphine remains a concern to public safety policymakers.
- As states have worked to build treatment capacity for OUD, they have integrated the required training for the waiver into their efforts, often partnering with professional associations to provide the in-person training hours. States have also dedicated funding to these trainings in both state budgets and via State Opioid Response (SOR) grant dollars. Because waiver trainings will now only be required for non-physician prescribers, states may need to quickly shift training plans and provider association partners.
- Reimbursement for these services may be administratively tied to the requirement to have a waivered prescriber among OUD care team members. As states have developed Medicaid waiver demonstrations and amended state plans to include OUD treatment services, language requiring waivered prescribers was incorporated to align with the federal policy. All of these documents, directives, and billing practices will need to be amended by states to ensure that physicians – now without the waiver – can seek reimbursement.
States can leverage this policy change to address many of the challenges that were previously posed by the waiver requirement in expanding access to this life-saving treatment:
- By allowing all licensed physicians to prescribe buprenorphine to a maximum of 30 patients in their first year, this policy change helps to normalize OUD treatment as part of health care, reflecting a long trend of integrating behavioral health and primary care practices. This helps to create administrative ease for providers and payers and reduces logistical barriers for patients.
- Stigma regarding OUD has long posed a challenge for states in their efforts to expand treatment capacity, and this change at the federal level represents a sanctioning and approval of this component of treatment that may help to alleviate that stigma.
- Emergency departments have been increasing their efforts to transition individuals who use opioids and have overdosed to buprenorphine, though this approach previously required that a waivered prescriber be present at all times in the hospital setting. All emergency department physicians will now be able to administer buprenorphine onsite if necessary.
While this change opens up opportunities for physicians to expand their OUD treatment services, it also leaves many practical questions unanswered. Non-waivered physicians who previously did not obtain the waiver and who decide to begin prescribing buprenorphine in light of this new policy may want additional guidance from their states to feel comfortable prescribing, particularly for non-waiver education and billing practices.
The National Academy for State Health Policy (NASHP) will continue to follow policy changes in the treatment of OUD as they emerge from Congress and the incoming Biden Administration.
Massachusetts Increases Adolescent Substance Use Treatment by Building Primary Care Provider Capacity
/in Policy Blogs, Featured News Home Behavioral/Mental Health and SUD, Care Coordination, Chronic and Complex Populations, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration /by Veronnica ThompsonTo increase much-needed early identification and treatment of adolescent substance use – and prevent the onset of substance use disorder – the Massachusetts Child Psychiatry Access Program and the Adolescent Substance Use and Addiction Program at Boston Children’s Hospital partnered to offer readily available consultation services to the state’s primary care providers and their adolescent patients with substance use needs.
Early intervention in adolescent substance use has the potential to promote healthy development, facilitate more integrated care to address related behavioral health concerns, and reduce development of a substance use disorder (SUD), resulting in significant cost savings to states. But many primary care providers (PCPs) report they are not comfortable managing the substance use needs of their adolescent patients and only 10 percent of adolescent patients who need SUD treatment receive it. The Massachusetts model provides an easily accessible expert resource to bolster access, early intervention, and primary care provider capacity to respond to this health care need.
Background
Substance use among adolescents is common. In 2019, 29 percent of US adolescents reported current use of alcohol with 13.7 percent reporting binge drinking within the past 30 days. During this same timeframe, approximately 22 percent of adolescents reported using marijuana. Among adolescents who have used substances at any point in their lifetime, 37 percent reported using marijuana and 14.3 percent reported misusing prescription opioids.[1]
View NASHP’s interactive map, State Strategies to Promote Children’s Preventive Services, to learn which states have Medicaid measures or incentives for children’s behavioral health screening.
While most adolescents who try substances, such as alcohol or marijuana, do not develop an SUD, substance use at an early age can be an important predictor of later life SUDs.[2] The majority of those with SUDs started using substances before age 18 and developed a disorder by age 20.[3] This risk is greatest for those who begin use in their early teens. In total, SUDs cost state Medicaid programs approximately $7 billion annually.[4] Even brief substance use that does not meet criteria for an SUD can affect normal adolescent brain development and key social transitions, resulting in potential long-term consequences.[5],[6] Despite the prevalence and well-documented effects of adolescent substance use, only 10 percent of 12- to 17-year-olds in need of substance use treatment actually receive services.[7]
As states explore opportunities to increase access to substance use services for adolescents, there is growing interest in the integration of behavioral health into primary care settings. This case study focuses on the Massachusetts Child Psychiatry Access Program’s partnership with the Adolescent Substance Use and Addiction Program to strengthen the identification and treatment of adolescent substance use within primary care settings.
Massachusetts Child Psychiatry Access Program
In 2003, Massachusetts launched a pilot program, the Massachusetts Child Psychiatry Access Program (MCPAP), to assist primary care providers managing the mental health needs of their patients. Originally developed by the University of Massachusetts Medical School under a grant from the Centers for Medicare & Medicaid Services and MassHealth (the state Medicaid program), MCPAP expanded statewide in 2004 under the Massachusetts Behavioral Health Partnership.[8], [9] MCPAP is a public health model that emphasizes universal screening, supports access to services in the appropriate setting based on need, and mitigates gaps in child psychiatry resources by building provider capacity.[10] Similar child psychiatry access programs (CPAPs) exist in at least 30 states and Washington, DC.[11]
MCPAP has seven regional children’s behavioral health consultation sites staffed by pediatric psychiatrists, licensed behavioral health providers, and care coordinators. These teams provide free, ongoing consultation and education to primary care providers serving children with mental health conditions. While PCPs must enroll in MCPAP, they can request a telephone consultation with MCPAP for any child, regardless of the child’s insurance status.[12] Requests to MCPAP can include:
- Questions about diagnosis and treatment options;
- Use of medications and screening tools;
- Available community resources;[13] and
- Requests that MCPAP staff provide diagnostic face-to-face or telehealth consultations with the youth/family.
MCPAP is financed by state general revenue funds (totaling $3.87 million in fiscal year 2019) under the Massachusetts Department of Mental Health, which covers operational costs under MCPAP, including staff salaries and administrative expenses. [14] While MassHealth does not currently claim Medicaid reimbursement for MCPAP consultation services provided to eligible enrollees, in-person visits provided under the program are eligible for Medicaid reimbursement. For children with commercial insurance served by MCPAP (representing 60 percent of consultations), insurers reimburse the state for their members’ portion of MCPAP costs under a formula used by the state’s Pediatric Immunization Program Assessment.[15],[16]
Available outcome data on MCPAP suggests promising results, particularly relating to the perceived competency of participating providers. Among the PCPs enrolled in MCPAP, 77 percent reported feeling comfortable treating attention-deficit hyperactivity disorder (ADHD) and 68 percent and 67 percent reported feeling comfortable treating depression and anxiety, respectively. However, fewer than 15 percent of these providers reported feeling comfort treating adolescent SUDs, suggesting a need for enhanced support.[17]
Partnership Approach
In 2019, MCPAP entered into a partnership with the Adolescent and Substance Use and Addiction Program (ASAP). Based at the Boston Children’s Hospital, ASAP is a specialty clinic that provides adolescent substance use services, including in-person comprehensive evaluation, diagnostic assessments, and treatment services (e.g., therapy and medication-assisted treatment). Using a team-based approach, ASAP staff include developmental-behavioral trained pediatricians, addiction medicine specialists, licensed social workers, and child and adolescent psychiatrists who are uniquely equipped to serve adolescents with a full range of substance use problems and disorders.[18]
The ASAP-MCPAP partnership operates using the existing MCPAP structure, in which PCPs enrolled in MCPAP submit consultation requests to their regional MCPAP team via telephone. Substance use-specific requests are then routed to an ASAP clinician for additional information and education. Similar to MCPAP, consultation services under ASAP are available to all adolescents regardless of their insurance status.
Depending on the nature of the request, ASAP clinicians consult on a variety of care management activities, such as brief intervention tools and behavioral contracting, medications to curb withdrawal and drug testing programs, and referrals to behavioral health services, including the ASAP clinic.[19] The partnership with ASAP costs $70,000 annually and is funded using available state funds appropriated to support MCPAP.[20] These appropriated funds cover a portion of ASAP clinicians’ time, allowing them to provide consultation services under MCPAP.
Massachusetts Child Psychiatry Access Program and Adolescent and Substance Use and Addiction Program Partnership Model
Since the ASAP-MCPAP partnership launched in October 2019, requests for substance use-specific consultation have steadily increased. While some incoming calls to ASAP are critical (e.g., a recent overdose), most questions relate to more routine adolescent substance use problems (e.g. excessive marijuana use) and requests for referrals. These initial utilization trends mirror those seen when MCPAP first launched. Drawing from the lessons learned from MCPAP’s early years, ASAP and MCPAP are using these initial consultation requests as an opportunity to promote stronger primary care management.[21] For example, ASAP clinicians often begin by assisting a provider with a referral or obtaining a buprenorphine waiver for medication-assisted treatment for an opioid use disorder. As PCPs continue to submit requests, ASAP clinicians will gradually empower them to manage their adolescent patients’ substance use needs independently. While building primary care providers’ clinical competency and capacity takes time, this approach has the effect of sustainably improving access to adolescent substance use treatment services over the long-term.
As the ASAP-MCPAP partnership continues to evolve and telehealth becomes more widely accepted due, in part, to COVID-19, ASAP-MCPAP is piloting a program in which PCPs connect adolescents to SUD counselling by calling the ASAP-MCPAP. Under this pilot, an ASAP clinician submits third-party reimbursement claims for any counselling rendered, with MCPAP providing supplemental funds to offset the ASAP clinician’s downtime.[22] By offering telephonic substance use treatment under the ASAP-MCPAP, there may be additional consultation requests, and thus, more opportunities to strengthen providers’ capacity to manage adolescent substance use needs in primary care.
Conclusion
In an effort to increase access to substance use services for adolescents, Massachusetts successfully expanded MCPAP through a partnership ASAP to strengthen the identification and treatment of adolescent substance use by building the capacity of PCPs. With child psychiatry access programs (CPAPs) in at least 30 states and Washington, DC, Massachusetts’s partnership model can inform other states’ efforts to augment their CPAP to better support adolescent substance use needs.[23]
Notes
[1] “Prescription Opioid Misuse and use of Alcohol and Other Substance Among High School Students-Youth Risk Behavior Survey,” Department of Health and Human Services, Centers for Disease Control and Prevention, 2019. https://www.cdc.gov/mmwr/volumes/69/su/pdfs/su6901a5-H.pdf
[2] “Principles of Adolescent Substance Use Disorder Treatment: A Research-Based Guide,” National Institute on Drug Abuse, 2014. https://d14rmgtrwzf5a.cloudfront.net/sites/default/files/podata_1_17_14.pdf
[3] Dennis, M.; Babor, T.F.; Roebuck, C.; and Donaldson, J. Changing the focus: The case for recognizing and treating cannabis use disorders. Addiction 97:(s1):4–15, 2002.
[4] Mark, T., et al., Insurance financing increased for mental health conditions, but not for substance use disorders, 1986-2014. Health Affairs, June 2016. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0002
[5] National Institute for Drug Abuse, “Principles of Adolescent Substance Use Disorder Treatment: A Research -Based Guide”
[6] “Teen Substance Use and Risks,” Department of Health and Human Services, Centers for Disease Control and Prevention. Accessed October 1, 2020. https://www.cdc.gov/ncbddd/fasd/features/teen-substance-use.html
[7] “Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings,” Substance Abuse and Mental Health Services Administration, 2013.
[8] Dube, N., “Massachusetts Child Psychiatry Access Project,” Objective Research for Connecticut’s Legislature Research Report, 2013. https://www.cga.ct.gov/2013/rpt/2013-R-0011.htm
[9] Massachusetts Behavioral Health Partnership is the state’s contracted Medicaid mental health and substance abuse provider.
[10] “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program. Accessed October 1, 2020. https://www.mcpap.com/About/OverviewVisionHistory.aspx
[11] “The Network,” The National Network of Child Psychiatry Access Programs. Accessed November 9, 2020. https://nncpap.org/thenetwork.html
[12] “Overview, Vision, and History,” Massachusetts Child Psychiatry Access Program
[13] Dube, Massachusetts Child Psychiatry Access Project
[14] “Budget Summary FY2019, Child and Adolescent Mental Health Services,” Office of the Governor. Accessed October 2, 2020. https://budget.digital.mass.gov/bb/gaa/fy2019/app_19/act_19/h50425000.htm
[15] John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.
[16] Code of Massachusetts Regulations: 104 CMR 30.08, “Massachusetts Child Psychiatry Access Program Assessment,” February 8, 2019. https://www.mass.gov/files/documents/2019/02/11/jud-lib-104cmr30.pdf
[17] John Straus, Sharon Levy, “Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence,” Aspen Institute, May 2020. https://ascend.aspeninstitute.org/webinar-stopping-behavioral-health-and-substance-use-disorders-where-they-start-prevention-and-treatment-in-adolescence/
[18] “Overview: Adolescent and Substance Use Program,” Boston Children’s Hospital. Accessed October 2, 2020. http://www.acaam.org/wp-content/uploads/2017/04/Pharmacologic-Treatment-in-Pediatric-PC_FINAL-LEVY-AMFDA_LiveLink_2017_04_03-003CBS-first.pdf
[19] Straus and Levy, Stopping Behavioral Health and Substance Use Disorders Before They Start: Prevention and Treatment in Adolescence
[20] John Straus. (Massachusetts Child Psychiatry Access Program Founding Director) Email. September 22, 2020.
[21] Ibid.
[22] Ibid.
[23] “The Network,” The National Network of Child Psychiatry Access Programs. Accessed November 9, 2020. https://nncpap.org/thenetwork.html
Acknowledgements: This case study is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. The information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
States Work to Improve Long-Term Care in the Age of COVID-19
/in Policy Ohio, Washington, Wisconsin Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, COVID-19, Health Equity, Long-Term Care, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, State Recommended Resources, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Paige SpradlinNursing home residents account for at least one-third of COVID-19 deaths, and this disparity reveals numerous problems with infection control in institutional settings. As a result, many states are rethinking and restructuring their long-term services and supports (LTSS) programs.
A recent National Academy for State Health Policy (NASHP) annual conference session explored what states have learned during the current health crisis that could improve LTSS during and beyond the pandemic. State officials from Washington State, Wisconsin, and Ohio highlighted their states’ responses to the current crisis, emerging innovations, and prospects for restructuring LTSS in a post-COVID-19 era.
Maximizing the Flexibility of Home- and Community-Based Waiver Services
Washington State, home to the first nursing home to be ravaged by COVID-19 in the United States, immediately worked with federal partners to maximize the flexibility of home- and community-based waiver services following its first reported case. The state was among the first to receive approval from the Centers for Medicare & Medicaid Services (CMS) for its 1135 and 1115 Medicaid waivers, which provided enrollees with increased access to services during the COVID-19 pandemic and additional supports to LTSS workers. State officials noted that the presumptive eligibility measures incorporated into these new waivers ensured that individuals were able to access the LTSS they need without having to wait for their applications to be fully processed. This flexibility has helped minimize administrative burdens on eligibility workers as states face increased demands on their Medicaid programs.
Like Washington State, Wisconsin utilized waivers to implement much-needed flexibility within its home- and community-based services (HCBS) provided through the state’s 1915(c) Medicaid waiver. Importantly, the state expanded the ability of its HCBS agencies to provide waiver services remotely, including care coordination and day services. The state also modified service delivery for Medicaid acute primary services, allowing these to be delivered through telehealth and other technologies to comply with social distancing.
Leveraging State Resources to Prevent and Contain Outbreaks for High-Risk Individuals
To contain and prevent outbreaks, Ohio relied on the following guiding principles to support its nursing facilities throughout the pandemic:
- Leverage regional and local leadership to coordinate a unified response; and
- Provide resources to support nursing facilities, including additional health services and technical assistance. These efforts were supported by $314 million from the US Department of Health and Human Services (HHS), some of which was provided by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, that was specifically dedicated to Ohio skilled nursing facilities (SNFs). Each SNF in Ohio with six or more certified beds was eligible to receive a fixed distribution of $50,000 plus an additional $2,500 per bed.
To coordinate a unified state COVID-19 response, Gov. Mike DeWine and leaders from a major hospital chain created three health care zones divided among the state’s large metro areas to manage hospital capacity and maintain patient level of care during an anticipated surge in hospitalization services. State officials in the three health care zones paired nursing facilities with local hospitals to manage distribution of personal protective equipment (PPE) and to ensure that staff were well-equipped to treat patients.
Additionally, the state developed the following resources to support nursing facilities, staff, and patients throughout the pandemic:
- A toolkit developed by the Ohio Department of Aging, Department of Health, Department of Developmental Disabilities, and Department of Medicaid to assist nursing facilities with assessing residents and determining their care needs during a COVID-related surge in service utilization;
- Increased testing services for nursing facility staff as mandated by a Public Health Order signed by the director of the Ohio Department of Health and conducted by the Ohio National Guard over a period of two months; and
- Congregate Care Unified Response Team (CCURT) Bridge Team, composed of staff from the Ohio Department of Health and Ohio Department of Medicaid, to assist nursing home staff with decision making in emergency situations and coordinating facility communication with relevant state agencies, the Emergency Operations Center, health care zones, and hospitals in the area.
Many of the steps taken by Ohio state officials track with the principal recommendations issued by the CMS-appointed Coronavirus Commission Report for Safety and Quality in Nursing Homes, including establishing a statewide strategy for testing in nursing homes, coordinating with state and local leadership, leveraging resources to support the nursing home workforce, and assembling a long-term care emergency response team to evaluate and guide emergency care coordination. With these strategies and systems in place, Ohio and other states now have the infrastructure to better manage infection control in institutional settings for future public health emergencies.
Post-COVID-19 Planning
While many of the policy changes highlighted here are temporary and in effect only during the pandemic, it is important to understand the impact of these changes on cost and quality of life to determine which, if any, should be retained after the pandemic. State officials from Washington State, Ohio, and Wisconsin reported they found the following flexibilities especially helpful:
- Presumptive eligibility for LTSS, so the state can initiate home- and community-based services as quickly as possible;
- Waiving plan signatures and self-attestation in favor of post-enrollment verification to ensure that enrollees receive timely supports; and
- Flexibilities for respite care for family caregivers, particularly those supporting individuals with intellectual and developmental disabilities, to reduce stress and burnout.
State officials noted it would be helpful to receive support from CMS in retaining these flexibilities. State officials also suggested that broader legislative changes to Medicaid, such as streamlining Medicaid authorities that support HCBS and making HCBS mandatory state plan services on par with nursing home care, would help reduce administrative complexity and facilitate rebalancing efforts.
Q&A: How Louisiana Has Retooled its Harm Reduction Services for Vulnerable Populations during COVID-19
/in Policy Louisiana Blogs, Featured News Home Behavioral/Mental Health and SUD, Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Health Coverage and Access, Health Equity, HIV/AIDS, Physical and Behavioral Health Integration, Population Health, Safety Net Providers and Rural Health, Social Determinants of Health /by Eliza Mette, Mia Antezzo and Jodi ManzAs drug overdose deaths accelerate during the COVID-19 pandemic, states are working to ensure that a continuum of services, including access to harm reduction programs, remain available to people with substance use disorder (SUD). The National Academy for State Health Policy (NASHP) recently spoke to Louisiana’s Viral Hepatitis Coordinator Emilia Myers and STD/HIV/Hepatitis Program Deputy Director Anthony James to learn how the state is continuing to provide harm reduction services during the pandemic.
Louisiana authorizes cities, including New Orleans, Baton Rouge, Shreveport, and Alexandria, to operate syringe services programs (SSP). The state has helped maintain these programs by targeting federal grants and through close cooperation between state and community partners.
How have the challenges posed by COVID-19 impacted the day-to day operation of harm reduction services in Louisiana?
Louisiana has six active SSPs across the state. They have stepped up to the challenges of this pandemic and have continued to provide their services, essentially without interruption. They’ve been able to do so through some very innovative approaches, such as hotlines and mail-based naloxone services, and by moving away from brick-and-mortar SSPs. The Louisiana Department of Health (LDH) has worked to improve its relationships with SSPs and link them with their respective local health departments. One result of this manifested in New Orleans where, right when COVID-19 started to ramp up, the city started providing residences for folks who were experiencing homelessness. SSPs went out to the hotels that were housing people to bring harm reduction services to them.
We are also using federal State Opioid Response (SOR) grant dollars in collaboration with the Office of Behavioral Health to fund SSP navigators and federal Opioid Overdose Data to Action (OD2A) dollars in collaboration with the Bureau of Community Preparedness to fund Linkage to Treatment Coordinators (LTCs), who prioritize people who inject drugs (PWID) who have fallen out of hepatitis C treatment. If they are also willing to talk about their drug use, the LTC will conduct a Screening, Brief Intervention and Referral to Treatment (SBIRT). We’ve also been using OD2A funds for our marketing campaign to raise awareness of integrated and co-located care for OUD (opioid use disorder), hepatitis C, HIV, and SSPs to reduce harms associated with substance use disorder, which we hope to continue.
Luckily, there is buy-in to this work. About a year ago, together with the Office of Behavioral Health and Bureau of Community Preparedness, we developed a state health department-wide, harm-reduction crosswalk, which was an environmental landscape analysis of who’s doing what in infectious disease, who’s doing what in OUD, and how we can create no-wrong-door systems of care. We’ve had some modest gains as a result, including braiding select government funds, scaling up SSP-based OEND (overdose education and naloxone delivery), increasing opt-out hepatitis C testing at select human service district agencies and cross-training OBOT (office-based opioid treatment) providers statewide to deliver both medication-assisted treatment for OUD and treatment for hepatitis C and we are looking to build on our momentum. Our state agencies have innovative leaders that make connections for more effective public health and behavioral health collaboration and care touch points, and we’re fortunate to have trailblazers that keep this work moving along.
How have people with comorbid HIV and hepatitis C diagnoses been affected by COVID-19, and how has the state responded?
We know folks who are coinfected are one of the populations most vulnerable to unemployment, poverty, lack of access to health care, and they generally have a lot of competing priorities between trying to take their medications and live their lives. Anecdotally, we are seeing more people accessing SSPs and needing supplies, and SSPs are trying to accommodate that increased demand. With an increase in utilization of SSP services, we hope there will not be an increase in overdoses and or increases in HIV and hepatitis C transmission. I think COVID-19 has really turned access into a challenge and created additional burdens for vulnerable populations, so we have to look at the issue through a health equity lens. There are a lot of systemic challenges and barriers that have been exacerbated by the pandemic, and people’s health has become a lesser priority because they’re trying to survive day to day.
Within our Hepatitis C Elimination Plan activities [featured in an April 2020 NASHP case study], we have seen decreases in testing and treatment as a result of the pandemic. Before we launched our program, 61 people per month were starting curative treatment. After implementation, we were seeing on average 478 people per month starting treatment. At the start of the COVID-19, that number dropped back down to an average of 155 people per month, but since September 2020, testing and treatment utilization has picked back up. This has forced us to learn how to get testing and treatment outside of brick and mortar treatment facilities, because people are anxious of going into health care systems. Because of funding reductions and other impacts of COVID-19, we revisited our hepatitis C strategy to ensure we were focused on realistic and achievable objectives for the second year of the plan, and reassess what Years 3 through 5 will look like. COVID-19 has forced us to pivot and continuously innovate hepatitis C service delivery. We will use this as an opportunity to leverage our response and facilitate a larger push in harm reduction.
How does Louisiana’s harm reduction approach support health equity and reduce disparities?
In both the LDH and STD/HIV/Hepatitis Program mission statements, we focus on addressing health equity and racial disparities across the board. Disparities in health care exist and are associated with worse health outcomes, for example the HIV/HCV coinfection diagnosis and prevalence rates are disproportionally higher among Black males primarily in the Baton Rouge and New Orleans areas. Looking at the mono-hepatitis C surveillance data, there hasn’t been a lot of variability in who’s being diagnosed by race. We see disparities in rates of infection by age – we have baby boomers and people who inject drugs getting infected, so we have this bimodal distribution. In an effort to address these disparities in the context of the current hepatitis C/OUD syndemic, we have to pinpoint shortcomings in hepatitis action towards people who actively use drugs and expand primary prevention through harm reduction because treating your way out of a hepatitis C epidemic isn’t feasible. PWID are increasingly researched, but their ability to tell their own stories and provide input into the programs and services they utilize has been historically limited due to stigma. Louisiana is changing that by leveraging community wisdom through community advisory boards to inform evidence-based service delivery. We move this work forward through a core set of values to help us ensure that the services that we and our community partners provide are moving in an equitable direction.
How has the pandemic necessitated or encouraged new strategies or partnerships?
One of our strategies has been offering provider training. We’ve leveraged Project ECHO to train providers how to leverage telemedicine to treat and manage hepatitis C virtually, revamping remote care. There has been a lot of engagement from clinicians.
There was also a decline in hepatitis C and HIV testing at the start of COVID-19. Our community-based partners have conducted risk mitigation strategies to safely re-engage people in testing. Now that they’ve been able to get PPE, they are able to conduct testing in community settings again.
We are also prioritizing data sharing and maximizing opportunities to form strong partnerships, because the syndemic of hepatitis C, HIV, and drug overdose is really intertwined, and COVID-19 has only made things more challenging. Reinforcing our partnerships and leveraging data sharing, in addition to amplifying the voices and wisdom of community members, is helping us make these programs work for the people who rely on them.
What would you say are your greatest lessons learned from COVID-19?
We really need to lean into interdisciplinary telemedicine for comprehensive care, especially for the hard-to-reach communities in high-burden regions of the state. COVID-19 has caused so much slow down, but also additional time to re-assess what we’re doing. In this context, developing robust telemedicine programs will be critical. The next challenge will be how to integrate offerings into clinical care beyond the COVID-19 pandemic so that a “one-stop-shop” PWID service bundle will become an increasingly ordinary part of care with movement towards the goal of reducing disparities in infectious diseases and opioid use disorder treatment access.
How New York Is Safeguarding Pregnant Women during the COVID-19 Pandemic
/in Policy Blogs, Featured News Home Care Coordination, Chronic and Complex Populations, COVID-19, Eligibility and Enrollment, Health Equity, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Taylor PlattA Centers for Disease Control and Prevention (CDC) study published in September found that pregnant women, especially Black and Latinx, are at increased risk of severe illness from COVID-19 compared to non-pregnant individuals. They are more likely to be admitted to intensive care units (ICU), receive invasive ventilation, and are at increased risk of death.
In response to COVID-19, several states, including New York, are working closely with the CDC to collect data on COVID-19 and pregnancy and implement guidelines to improve women’s outcomes and address disparities. Earlier this year, the New York COVID-19 Maternity Task Force submitted a report with recommendations to the governor, who is now implementing these actions.
Background
At the start of the COVID-19 pandemic, little was known about the impact of the disease on pregnant women. CDC and the American College of Obstetricians and Gynecologists (ACOG) have been monitoring data about pregnant women infected with the coronavirus and publishing updated guidance as new information comes to light. Recently, the CDC determined that pregnant women are at increased risk for severe illness from COVID-19. In response, last April New York Gov. Andrew Cuomo formed the COVID-19 Maternity Task Force.
In a recent report, the CDC summarized maternal and birth outcomes of hospitalized pregnant women with confirmed COVID-19. Between March and August, 598 hospitalized pregnant women tested positive for COVID-19:
- Approximately 55 percent were asymptomatic at the time of admission;
- 42.5 percent self-identified as Hispanic or Latino;
- 26.5 percent were non-Hispanic Black; and
- 20.6 percent had at least one underlying condition – asthma and hypertension were the most prevalent.
Additionally, symptomatic pregnant women were at an increased risk for ICU admission and mechanical ventilation. This new data continues to highlight how COVID-19 disproportionally impacts Black and Latinx populations and has implications for providing care to pregnant women during the pandemic.
New York’s Actions
New York’s COVID-19 Maternity Task Force report includes the following recommendations:
- Diversify birthing site options to support patient choice to deliver at a hospital or a birthing center;
- Authorize at least one support person to accompany an individual during labor, delivery, and recovery;
- Universally test all pregnant patients for COVID-19;
- Ensure equity by continuing to engage community members and community-based organizations;
- Increase messaging and education of pregnant patients about COVID-19 and perinatal care; and
- Encourage the New York State Department of Health to continue collaborating with academic institutions, regional perinatal centers, and medical organizations to review the impact that COVID-19 has on pregnancy and newborns.
Gov. Cuomo accepted all of the task force’s recommendations and New York’s Department of Health (DOH) has begun to implement the recommendations. The original executive order issued in March addressing having support people present during labor has been amended to include support during labor, delivery, and recovery, and now includes doulas as part of the care team.
Following the task force recommendations, hospital and health systems have rolled out universal COVID-19 testing for pregnant women, and DOH has approved two new temporary birthing centers as a result of the streamlined process to establish additional birthing centers during the pandemic. DOH will continue to accept applications for midwifery birth centers and provide emergency approvals during the public health emergency to ensure access to safe perinatal care and provide a variety of birthing options to parents.
DOH partnered with the University at Albany School of Public Health to conduct an early literature review on the impact of COVID 19 and pregnancy. Results were shared with staff from regional perinatal centers across the state for feedback and discussion. The final version of the literature review was posted on the New York State Perinatal Quality Collaborative website in June 2020.
The New York State Perinatal Quality Collaborative, in partnership with the American College of Obstetrics and Gynecology District II, hosted statewide interactive webinars on obstetrical care and implicit bias within the context of the COVID-19. Educational webinars related to the management of pregnant people during the COVID-19 pandemic featured state obstetric leaders sharing their experiences, successes, and challenges related to treating pregnant and postpartum people during the COVID-19 pandemic. Webinar participants were able to submit questions during the live event or prior to the event by email. In addition to the obstetric-focused webinars, the collaborative also hosted a neonatal-focused webinar relating to COVID-19 that addressed the testing and care of newborns. All webinars were recorded and each has been posted on the public section of the collaborative’s website.
Resources to Improve Maternity Care during COVID-19
Throughout its response to COVID-19, New York’s DOH has been committed to promoting health equity, especially as it relates to maternity care. It convened a workgroup that included community members to provide input and oversight into the development of education and messaging materials related to COVID-19, which is under development. A webinar conducted in partnership with the collaborative. on COVID-19 and Maternal Equity was held on June 5, 2020. This webinar features a panel discussion of maternity and racial justice experts led by Joia Crear-Perry, MD, FACOG, of the National Birth Equity Collaborative on the impact of COVID-19 on the birth equity and included stories of lived experience shared by a Rochester mother who had given birth during the pandemic and a community health worker supporting pregnant women in the Bronx.
As states continue to confront COVID-19 and its impact on health care delivery, it will be important for states to consider new CDC data on pregnant women and best practices for how to protect women and children, especially pregnant women of color. The National Academy of State Health Policy will continue to track state actions on COVID-19 and pregnant women. For more information on COVID-19 and pregnancy explore this NASHP Infographic: How State Medicaid Programs Can Use Telehealth to Serve Pregnant Women during COVID-19 and blog, States Implement Strategies to Safeguard Pregnant Women during the COVID-19 Pandemic.
States Use CHIP Health Services Initiatives to Support Home Visiting Programs
/in Policy Blogs, Featured News Home CHIP, Chronic and Complex Populations, Infant Mortality, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Physical and Behavioral Health Integration /by Taylor PlattMaternal and infant mortality rates in the United States have been steadily rising over the past decade, with stark racial disparities between White and Black mothers and their babies. Black infants are twice as likely to die than White infants, and Black mothers are four-times more likely to die from pregnancy-related causes than White women.
Evidence-based home visiting programs, such as those funded by the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV), play an important role in improving the health and well-being of the maternal and child health (MCH) population, especially during stressful periods of economic downturns and the COVID-19 pandemic. In addition to MIECHV funding, the Children’s Health Insurance Program’s (CHIP) Health Services Initiatives (HSIs) are a funding opportunity available to states to support home visiting programs.
For an indepth report about public insurance financing of home visiting services and additional information about CHIP HSIs, read/download Public Insurance Financing of Home Visiting Services: Insights from a Federal/State Discussion.
Research shows home visiting programs improve overall maternal and infant health outcomes, increase maternal depression screenings, reduce child abuse and neglect, promote child development and school readiness, and improve coordination and referrals for community resources.
To support these programs, states use an array of private and public funds, including Medicaid and the CHIP funding, to support home visiting services. Specifically, CHIP HSIs are available to states to support a range of child health services, including home visiting since CHIP’s inception in 1997. Recently, there has been an uptick in the number of states using HSIs with 45 federally approved HSIs established between 2016 to 2019.
The Centers for Medicare & Medicaid Services (CMS) approve state HSIs through a state plan amendment that includes performance metrics to measure impact and outcomes of the programs. CHIP HSIs are designed to serve children under age 19 who are eligible for Medicaid or CHIP, but they can be designed to improve the health of a broader population of children beyond those eligible for Medicaid or CHIP.
HSIs can focus on direct services, public health initiatives, or ongoing social, behavioral health needs. Funding for HSIs comes from a combination of state and federal funds. A state draws federal funds from its CHIP administrative allocation, which is 10 percent of its CHIP block grant spending, to help fund an HSI. These funds are provided at the state’s CHIP match rate. States must consider all of their administrative expenditures, including those required to operate their CHIP programs, such as staff, managed care fees, systems upgrades, etc. to ensure there are remaining funds, within a 10 percent cap, before committing funds to an HSI project.
As of 2019, there are 71 approved HSIs in 24 states. At least three states currently have HSIs that include home visiting services and one state recently received CMS approval to start an HSI that includes home visiting services.
- Alabama’s State Plan Amendment was approved in September 2019 to implement an HSI to provide case management and care coordination to low-income, high-risk pregnant women and their infants in three counties to improve pregnancy outcomes and infant health for up to one year postpartum. The case management services include home visits.
- The Arkansas SafeCare program is a structured, evidence-based and in-home parenting program that has a home visitor and parent work together to create a safe home environment. The home visitor assists the parent in providing structure and routines, while encouraging systematic health decision-making to keep children safe in their homes. Parents are provided with useful tools, such as books, thermometers, childproof safety locks, and other learning materials to use in their family environment to keep children safe. The home visitor delivers weekly or biweekly home visits for approximately 18 to 22 weeks. More information can be found about the state plan amendment here.
- Massachusetts has two CHIP HSIs that include home visiting services. The first, Healthy Families, is a newborn home visiting program that provides home visits, a six-week neonatal and postnatal parenting education support group series, and parent-child interaction groups to support positive parent-child relationships. The HSI is designed to serve families with at-risk newborns. The Young Parent Support program is another CHIP HSI that provides funding for community-based organizations that provide outreach, home visits, mentoring, and parent groups to strengthen the skills of young parents.
- Missouri’s newborn home visiting program serves at-risk, low-income pregnant and postpartum women and their children up to five years of age. Clinical staff and other trained professionals provide a range of services to families, including group training sessions and connection to needed resources. The CHIP HSI’s goal is to increase healthy pregnancies and positive birth outcomes, as well as decrease child abuse and neglect through its home-based services.
States are implementing evidence-based home visiting programs to improve health outcomes for women, children, and their families. CHIP HSIs are one of many funding mechanisms states can use to help expand their home visiting services and continue to improve the lives of children and their families, especially at a time when the COVID-19 pandemic has brought new challenges for states and families. In spite of these challenges home visiting remains an important service for women, children, and families.
States will soon be faced with critical budget challenges brought on by the COVID-19 pandemic and will have to make tough decisions about funding for home visiting services. CHIP HSIs provide one funding source states may want to use to help support home visiting services.
- For more information on financing home visiting, read the NASHP report, Medicaid Financing of Home Visiting Services for Women, Children, and Their Families.
- And for additional information on CHIP HSIs, explore NASHP’s report, Leveraging CHIP to Improve Children’s Health: An Overview of Stare Health Services Initiatives.
Public Insurance Financing of Home Visiting Services: Insights from a Federal/State Discussion
/in Policy Blending and Braiding Funding, Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, CHIP, Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Coverage and Access, Integrated Care for Children, Long-Term Care, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Palliative Care, Physical and Behavioral Health Integration, Population Health, Reimbursement Strategies, State Resources, The RAISE Family Caregiver Resource and Dissemination Center /by Taylor Platt and Karen VanLandeghemNASHP hosted a meeting of state and federal Medicaid, public health, and home visiting leaders to discuss key opportunities, challenges, and innovative approaches to enhance public insurance financing of home visiting services. Participants discussed strategies to enhance Medicaid and Children’s Health Insurance Program funding of home visiting services and strengthen state financing systems to support home visiting. This report summarizes the key themes discussed at this meeting, including critical policy levers, state strategies, and key considerations to enhance these efforts.
Introduction
Home visiting is a long-standing strategy that states use to improve the health and well-being of women, children, and their families, particularly those living in underserved and vulnerable communities. Home visits are often provided to families to deliver social, health, and educational services and can play an important role in addressing health needs throughout the life course. Home visiting programs can include screenings for physical, social-emotional, and developmental issues, case management, and family support and counseling. Services can also include promotion of well child visits and immunizations, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) services, prenatal and postpartum care, and education about healthy nutrition and physical activity.
They have been shown to increase important services, such as:
- Screening caregivers for depression and intimate partner violence;
- Improving school readiness for children; and
- Improving coordination and referrals to community resources.[1]
Home visiting programs have demonstrated cost savings in several areas, including reducing unnecessary health service utilization through a decrease in emergency room visits and decreased placement in special education services and grade repetitions.[2] One of the largest benefits from home visiting is decreasing a family’s need for public assistance.[3] Home visiting is a cost effective way to address social determinants of health and a way to support health care providers by ensuring that the diverse needs of families can be addressed and met outside of clinical care settings.
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program was established in March 2010. The federal program, administered by the Health Resources and Services Administration (HRSA), supports evidence-based, voluntary home visiting services for families with young children that reside in communities at risk for poor health outcomes.[4] In 2019, the program awarded approximately $351 million to 56 states, territories, and nonprofit organizations to support home visiting services, serving over 154,000 parents and children, and providing more than 1 million home visits nationwide.[5] While MIECHV is a critical federal program for states, the need for home visiting services far exceeds federal MIECHV funding to states. Approximately 18 million pregnant women and families could have benefited from home visiting services but were not served, according to 2018 data.[6]
Financing of home visiting services is a key factor in the availability of and access to home visiting services. States finance home visiting services through multiple federal and state funding streams in addition to MIECHV. These funding streams include Medicaid and the Children’s Health Insurance Program (CHIP), Temporary Assistance for Needy Families (TANF), the state Title V Maternal and Child Health (MCH) Services Block Grant, state general revenue funds, and private foundation support. Medicaid and CHIP can play a key role in supporting home visiting services. In 2019, nearly three-quarters (76 percent) of participants in the MIECHV program were enrolled in Medicaid.[7] Recognizing this important role, the Centers for Medicare & Medicaid Services (CMS) and HRSA issued a Joint Informational Bulletin in 2016 containing guidance to states on federal authorities, opportunities, and strategies for supporting home visiting services through Medicaid and the Children’s Health Insurance Program (CHIP).[8]
The National Academy for State Health Policy (NASHP), with support from the HRSA Maternal and Child Health Bureau (MCHB), hosted a meeting in January 2020 of state and federal leaders in Medicaid, public health, and home visiting to discuss key opportunities, challenges, and innovative approaches to enhancing public insurance financing of home visiting services. It is important to note that this meeting was held prior to the COVID-19 pandemic and states are now facing the ramifications of the pandemic, including reduced state budgets. Participants discussed strategies to enhance Medicaid and CHIP financing of home visiting services in states and strengthen state financing systems to support home visiting. The meeting provided an opportunity to collectively identify and discuss strategies for enhancing federal and state financing of home visiting programs. This document summarizes the key themes that were discussed at this meeting, and reflects discussion among state officials who participated in the meeting about the critical policy levers, state strategies, and key considerations for enhancing efforts in this area.
State Policy Opportunities to Increase Use of Public Insurance Financing
States have long-standing programs and investments that support home visiting for women, children and their families. Public insurance financing is a key part of these efforts in many states. A recent national report found that approximately 20 states use Medicaid and CHIP to finance home visiting services.[9] Several policy questions persist concerning the use of public insurance financing and braiding the array of federal, state, and private funding options available to states:
- Limited awareness about which elements of home visiting Medicaid and CHIP can reimburse for;
- Varying knowledge levels among home visiting stakeholders about how to navigate the Medicaid program;
- The administrative burden around tracking and reporting the impact of home visiting services on health outcomes;
- The need for integration and alignment among home visiting services and other child-serving systems; and
- The variability among states’ policy, programmatic, and system considerations resulting in the need for tailored and targeted financing strategies.
State health leaders who participated in the federal/state meeting (see Appendix B) identified the following policy areas that need additional focus and support relating to public insurance financing of home visiting services.
How can states ensure that home visiting programs are fully funded, particularly given the looming fiscal crises, to meet the needs of all eligible families. This requires complex braiding of federal, state, and private funding streams. Home visiting programs provide an array of services and supports to pregnant women, infants, and children, not all of which are Medicaid- and CHIP-reimbursable. Therefore, home visiting programs must be supported by multiple federal and state funding streams. State health leaders expressed the need to ensure that the full array of services (e.g., health services, social supports, home visitor transportation, provider training) are provided through home visiting programs, while leveraging financing of those services that can be covered by Medicaid and CHIP.
Limited awareness about public insurance financing options and the use of federal authorities in Medicaid and CHIP can hinder the use of these options in states. State Medicaid, MIECHV, and Title V MCH programs, and other stakeholders that administer home visiting services expressed the need for additional information and technical assistance about public insurance financing options and how to use and leverage them in states. Home visiting is not a mandated benefit or fully defined set of services under the federal Medicaid program. States must leverage one or more categories of benefits (e.g., case management, preventive services, and home health services) in order to use federal Medicaid and CHIP funds for home visiting services.[10] To leverage them effectively requires an in-depth understanding of the financing options available under Medicaid and CHIP, knowing which services are reimbursable, and strong cross-sector partnerships among state Medicaid and public health programs.
Complexities in state Medicaid and managed care plan rate setting can lead to variability in reimbursement rates for home visiting services among states. Rate setting for Medicaid is a complex process that involves ensuring rates are actuarially sound based on economy, efficiency, and quality.[11] State Medicaid agencies set their own rates for services through an actuarial process that takes into account base utilization, medical trend inflation, and risk adjustment.[12],[13] The actuarial process used to set Medicaid payment rates takes into account cost savings and the benefits of a service over a period of time. In the case of home visiting services, cost savings may not be realized until years after the service is delivered. Additionally, low usage of services can result in lower projected costs for the service, and therefore a lower baseline for the service when determining the overall capitation rate. Home visiting rates for select states underscore this variability – in Oregon, reimbursement is $355 per visit for home visiting delivered through targeted case management, in Minnesota public health nurses are able to bill $140 per visit, and in South Carolina, Medicaid reimburses $176 per visit.[14]
In addition to overall rate setting, state Medicaid agencies also must negotiate rates for home visiting services provided by managed care plans, in states that serve Medicaid beneficiaries through Medicaid managed care. Negotiating rates with managed care plans can be a challenge for several reasons. First, a wide range of services are provided in home visiting, making it difficult to establish a rate that fully covers all components of a home visit. Also, the benefits of home visiting services, like school readiness, reduced crime or domestic violence, and improved parent-child relationships,[15] may not be fully realized while a Medicaid beneficiary is a member of the Medicaid managed care plan and Medicaid enrollees often transition on and off of coverage over time, resulting in a potential disincentive for health plans to invest in services.
Medicaid and CHIP reimbursement rates can impact the availability of home visitors. Because home visiting is not a discrete service, reimbursement rates may be lower than what is needed to cover a full home visit, which includes costs for transportation for the home visitors and assistance in accessing non-Medicaid related services. Reimbursement levels can hinder the ability of states and community-based organizations to hire and retain professionals (e.g., public health nurses and other health and social service professionals) who deliver home visiting services. In a national survey of home visiting program managers, low salary was the most common reason (51 percent) for staff turnover.[16] Home visitor workforce shortages can lead to an inability for programs to fully reach and support the large population of families that need and can benefit from services.
Navigating state Medicaid billing policies and billing codes when providing services using a two- generation approach requires dedicated staff time. Home visiting programs are intentionally designed using a two-generation approach – a model that promotes caring for the mother and child together as one unit. In this case, determining correct codes for billing can be complicated and also depend on state Medicaid policy for Medicaid reimbursement of two-generation services. Federal guidance allows states to reimburse for services to a Medicaid-eligible mother or a Medicaid-eligible child for services that actively involve the child, are directly related to the needs of the child and such services must be delivered to the child and mother together, but can be claimed as a direct service for the child.[17] Given the different funding streams used to support services, administrators need to know what types of providers can be reimbursed by which funding streams (e.g., Medicaid or MIECHV) and the appropriate billing codes and procedures for all of the different services that home visitors provide.
Rules governing qualified provider requirements in Medicaid state plan amendments can limit which home visitors are reimbursed. Evidence-based home visiting models vary in their requirements for who qualifies as a home visitor.[18] Some programs require that nurses conduct a home visit, while other programs promote the use of community health workers or other trained staff. Federal Medicaid law[19] allows states to set reasonable standards relating to qualifications of providers under Medicaid.[20] Depending on the benefit, services can be provided by unlicensed practitioners who meet qualifications established by a state. Such benefits include the case management benefit, preventive services, and rehabilitative services benefit. Examples of reasonable standards states must set for providers include the ability to perform the service in a professionally competent manner and the infrastructure to bill.[21] State policies vary regarding terms for qualified providers for home visiting. Some states set the qualified provider based on the home visiting model being used (e.g., nurse family partnership), while others may use local health departments or other community-based organizations that already have qualified providers to deliver services.[22] The types of providers a state deems to be an eligible qualified provider may not always include the provider who is the home visitor. Additionally, in most cases the qualified provider rendering the home visiting service is not the same as the qualified billing provider (e.g., a physician, local implementing agency, or health department), which can add another layer of complexity to Medicaid reimbursement.
Navigating federal Medicaid authorities such as waiver requirements can impact the use of some Medicaid strategies. Federal Medicaid Section 1115 demonstration project authorities provide states with additional flexibility to design policy initiatives and programs that improve health care for Medicaid beneficiaries. The federal Section 1115 Medicaid waiver, for example, is a research demonstration waiver that is approved for an initial five-year period, and can be extended for up to an additional three to five years depending on the populations served.[23] A few states (e.g., Maryland and Vermont) have used Section 1115 waivers to support home visiting through Medicaid.[24] However, states at the meeting discussed that due to the intricacies of the federal waiver process this strategy is not commonly used to support home visiting services. One factor may be that states are required to demonstrate budget neutrality over the life of the demonstration project, usually lasting just a few years. While some home visiting outcomes, like those for pregnant women and newborns, may be more immediate, other health outcomes may not be evident until several years after the service is provided. Because of this states can experience challenges in demonstrating cost savings to continue to use Medicaid dollars through the 1115 demonstration waiver.[25]
Lack of alignment across federal and state data reporting requirements adds to complexities in demonstrating the impact of home visiting programs. States must submit separate federal program reports for different performance measures and indicators across the programs that support home visiting, creating challenges for state performance reporting. States often have to implement planning processes and dedicate resources to integrate home visiting efforts, create data tracking and reporting systems that align measures across an array of programs, and ultimately, build a statewide integrated home visiting program from multiple federal and state funding sources. These challenges are compounded by a lack of staff capacity to report on data, inadequate state reporting systems, and lack of comparability of data and reporting measures across federal programs including Medicaid and CHIP. Most states have few-to-no home visiting data tracking and reporting systems that fully capture home visiting data and thus, ease the reporting process as it relates to home visiting.
Financing Strategies and Innovations to Address Key Opportunities
State Medicaid, public health, and MIECHV officials who participated in the federal/state discourse meeting agreed that while there are policy areas in need of further support and focus, public insurance financing of home visiting provides important opportunities to increase the ability of states to provide critical home visiting services to MCH populations.
Participants described a range of public insurance financing strategies and innovations that they are using to support home visiting programs. These strategies include the use of:
- Medicaid-targeted case management;
- Medicaid managed care contracting processes;
- Federal Medicaid authorities (e.g., Section 1115 waivers);
- CHIP Health Services Initiatives (HSIs);
- Public/private partnerships, such as the Pay for Success model in South Carolina; and
- Value-based payment and bundling of home visiting services payments.
The state examples included below represent some of the leading innovations using public insurance financing and were reflected in the discussions and strategies highlighted during the meeting. These states – many of which were represented at the federal/state discourse meeting – took unique approaches to integrating public insurance into their financing of home visiting. Because lessons learned from these models formed the basis of discussions at the meeting, summaries of these models and some of their more innovative elements are highlighted. Additional information about these models is included in Appendix C and also has been previously widely reported on by NASHP and others.
Targeted Case Management
The most common Medicaid mechanism for financing home visiting is targeted case management (TCM). TCM is a service under Medicaid that helps enrollees gain and coordinate access to necessary medical, social, and educational care and other services tailored to their needs.[26] TCM helps enrollees gain access to needed services, but cannot be used to provide the underlying needed services. Traditionally, one way states have used TCM for MCH populations is to increase use of prenatal care through maternal and infant case management programs.[27] Use of TCM requires submission of a state plan amendment to CMS for approval. At least 33 states currently use TCM to finance home visiting services for prenatal care as a Medicaid benefit, and at least 30 cover it as a postpartum Medicaid benefit.[28] TCM was outlined in the CMS and HRSA joint informational bulletin as a strategy states could use to promote public insurance financing. Additionally, using TCM can help address the challenge of navigating the federal Medicaid Section 1115 demonstration process by only requiring a state plan amendment.
- The Kentucky Health Access Nurturing Development Services (HANDS) program, administered by the Kentucky Department of Public Health, is a voluntary statewide home visiting program that serves Medicaid-eligible parents during the prenatal period through the child’s third birthday. The program is supported by Medicaid through TCM and other state and federal funds. Kentucky uses state tobacco funds as the state match for federal Medicaid dollars. Services provided include health education, developmental and social-emotional screenings for children, domestic violence and perinatal depression screenings for parents/caregivers, and referral coordination.[29] Through coordinated efforts across state Medicaid and public health agencies, the program is delivered through local health departments using a fee-for-service payment model. Kentucky was able to leverage MIECHV funds to expand services beyond just first-time mothers.
Medicaid Managed Care Contracting
Nearly all states serve a majority of their Medicaid enrollees through Medicaid managed care (MMC) programs. As of 2017, 47 states and Washington, DC enrolled some of their Medicaid enrollees in Medicaid managed care plans.[30] The MMC contracting process presents opportunities for states to promote home visiting services for eligible pregnant women. State Medicaid programs contract with managed care plans to provide services and agree to a set per member per month payment for the services provided. Home visiting services can be included in the capitated payment rate in MMC. As more states transition Medicaid-eligible pregnant women to managed care, they are using MMC contracts to promote home visiting services.
- Michigan’s Maternal and Infant Health Program (MIHP) is administered by the state Medicaid agency and is the largest home visiting program in the state. MIHP is available to all pregnant women enrolled in Medicaid and their infants up to 12 months. The program promotes healthy pregnancies and positive birth outcomes via a standardized, system-wide process of case management.[31] The MIHP program is written into the Medicaid State Plan to allow Medicaid to fund the program. MIHP services have been rolled into the state’s Medicaid managed care contracts and managed care organizations (MCOs) can contract with MIHP providers to provide services. MIHP services include social work, nursing services (e.g., health education and nutrition education), breastfeeding support, nutritional counseling, and beneficiary advocacy services.[32] Recently, MIHP was approved as a MIECHV evidence-based model.
- Minnesota includes home visiting as part of its capitated payment rate under its managed care contracts. The state has a long history of using Medicaid to finance home visiting services. Minnesota requires the managed care plans to contract with local health departments to administer voluntary, evidence-based home visiting programs to Medicaid enrollees. At least five additional states use managed care to finance home visiting. The state legislature set the rate at $140 per visit to help ensure the reimbursement rate was not too low. Two states (Illinois and New Mexico) are working to implement demonstration projects through their managed care plans.[33]
- In its biennium budget, Virginia Medicaid seeks federal authority through waivers and state plan amendments to implement a home visiting benefit for at-risk pregnant women and postpartum women at risk of poor health outcomes. The intention is for this benefit to be included as part of the state’s managed care plans contracts allowing MCOs to contract with local providers for these services. At this time, funding for this process is unallotted due to COVID-19 and the Virginia General Assembly is expected to meet in a special legislative session to make a determination on this budget item. Early Impact Virginia officials, which is the alliance for early childhood home visiting programs, meets regularly with the Office of the Secretary of Health and Human Resources, the Office of the First Lady of Virginia, the Virginia Department of Health, Virginia Medicaid, and other relevant stakeholders to ensure in the development of the benefit and the potential for evidence-based models.
Federal Medicaid Section 1115 Demonstration Projects
Federal Medicaid waivers give states the flexibility to design home visiting services for Medicaid recipients. As previously mentioned, the Section 1115 demonstration project gives states additional flexibility to design and improve their programs by waiving certain provisions of federal Medicaid law. A few states have taken advantage of this federal Medicaid authority.
- Maryland’s Section 1115 demonstration project allows local government entities to apply for federal matching funds for Maryland’s Home Visiting Services (HVS) Pilot. The HVS Pilot provides home visiting services for high-risk pregnant women and children up to two years of age. The HVS Pilot is aligned with two-evidence-based models – (Nurse Family Partnership and Healthy Families America) – that focus on the health of pregnant women. Local government entities can apply to the program if they are able to fund 50 percent of HVS Pilot costs with local dollars. Key community partners must be identified to help deliver the pilot program. Approximately $2.7 million in matching federal funds are available on an annual basis and the HVS Pilot expenditures can total up to $5.4 million annually. The pilot operates until Dec. 31, 2021.[34]
CHIP Health Services Initiatives
An emerging federal initiative to increase public insurance financing of home visiting are CHIP Health Service Initiatives (HSIs). CHIP HSIs have been available to states since shortly after the passage of CHIP in 1997 to support a range of child health services including home visiting. CHIP HSIs are intended to serve children under age 19 who are eligible for Medicaid or CHIP, but can be designed to improve the health of a broader population of children.[35] HSIs are funded by a combination of state and federal money. States draw federal funds from the their CHIP administrative allocation, which is 10 percent of its CHIP block grant. HSIs can focus on direct services, public health initiatives, or ongoing social, and behavioral health needs. State HSIs are subject to CMS approval through a state plan amendment and must include metrics to measure impact and outcomes of the program.
At the meeting, some state officials expressed interest in developing a home visiting HSI. However, officials raised concerns about ensuring that programs are able to provide the full scope of home visiting services and the challenges of working in coordination with additional payers. Because home visiting is not a discrete health care service, leaders raised considerations and challenges, similar to ones raised for Medicaid, about using a CHIP HSI to fully support home visiting services. At least four states have home visiting CHIP HSIs.
- Arkansas’s HSI – SafeCare – focuses on delivering home visiting services to children at risk for placement in foster care. SafeCare is a structured, evidence-based, and in-home parenting program that has a home visitor and parent work together to create a safe home environment.[36] The home visitor assists the parent in providing structure and routines, while encouraging systematic health decision-making to keep children safe while in their homes. Parents are provided with useful tools, such as books, thermometers, childproof safety locks, and other learning materials to use in their natural family environment to keep children safe. The home visitor delivers weekly or biweekly home visits for approximately 18 to 22 weeks.[37]
Public/Private Partnerships
Some states have developed unique public/private partnerships to leverage home visiting to advance priorities for MCH populations. South Carolina wanted to improve birth outcomes and address infant mortality rates. State officials built a public/private partnership to further support the state’s Nurse Family Partnership (NFP) home visiting program. During the discourse, state officials acknowledged needing significant incentives and political will from an array of state agencies, the legislature, and the private sector to create the Pay for Success (PFS) program. While the public/private partnership is an opportunity states are interested in exploring, there is a significant amount of administrative work to get this type of model off the ground.
- South Carolina’s Pay for Success model relies on strong private-public partnerships. In the model, a private investor provides the upfront capital to implement an evidence-based social service program in collaboration with a government agency. The government repays the investor if the program meets the agreed-upon goal. South Carolina is currently using the PFS model in conjunction with Medicaid to expand the home visiting programs in the state. The PFS initiative focuses on improving health outcomes for Medicaid-eligible mothers and children. In 2016, the South Carolina Department of Health and Human Services, which administers Medicaid and the PFS initiative, used a 1915(b) Medicaid waiver to support NFP’s efforts.[38] The PFS initiative directed $30 million — $17 million from philanthropic funders and $13 million from Medicaid — to expand the NFP’s evidence-based services to an additional 3,200 first-time, low-income mothers across the state. South Carolina used a 1915(b) waiver because it allowed NFP to bill in real time for the cost of home visiting services, expand home visiting services, and waive the freedom of choice of providers for the NFP program. The program focuses on four outcome metrics to assess NFP’s impact:
- A reduction in preterm births;
- A reduction in child hospitalizations and emergency department usage due to injury;
- An increase in healthy spacing between births; and
- An increase in the number of first-time mothers served in areas with high concentrations of poverty.
The state made $7.5 million available for success payments based on NFP’s performance on each metric.[39]
Value-based Payment and Bundling of Home Visiting Services
Value-based payment (VBP) models and bundled payments were discussed as an opportunity states could use to increase public insurance financing of home visiting services. State Medicaid agencies are turning to VBP models as part of health system reform. Moving away from the traditional fee-for-service model that is based on volume of care, VBP models reward providers for reaching specific goals around the quality of care while taking into account cost considerations.[40] VBP models have been implemented to help better serve MCH populations using benchmarks such as prenatal care initiation, postpartum care, and reduction in early elective delivery rates.[41]
Bundled payments represent a single payment to providers for all services given to treat a condition during a predefined episode of care.[42] For example, Medicaid agencies can use a bundled payment for labor and delivery services. Currently, few states are using VBP or bundled payments for home visiting. State leaders expressed interest in pursuing these policy levers but acknowledged they are newer strategies that need further exploration.
- New York used a Section 1115 demonstration to promote Medicaid financing of home visiting services. The Medicaid Redesign Team (MRT) demonstrations assisted in delivery system transformation in New York with its transition towards VBP. Part of the demonstration included delivery system reform incentive payments (DSRIP). DSRIP programs that incentivize infrastructure improvements, care delivery redesign, and improvements in the quality of care for low-income populations and assist states in developing the infrastructure necessary for successful transition to New York provides incentive payments for meeting milestones on both system reform projects and outcome measures.[43] In addition to the DSRIP and VBP efforts, New York also pursued a First 1000 Days on Medicaid Initiative, in conjunction with the MRT waiver, aimed to improve outcomes for a child’s first three years of life. The initiative works across systems to improve outcomes for children on Medicaid. Statewide home visiting services are a key part of the initiative’s action plan to address social determinants of health for children on Medicaid, and has since been incorporated through a separate Children’s Design Home and Community-Based Services (HCBS)-focused program in its MRT demonstration. While expenditure authority for the DSRIP component of the MRT demonstration ended on March 31, 2020, expanded HCBS remains an active component of the MRT demonstration.[44]
Key Considerations and Next Steps
State leaders discussed several key considerations and opportunities to strengthen public insurance financing of home visiting services. In addition to the array of available Medicaid financing options, state leaders discussed the importance of taking advantage of federal authorities and initiatives, particularly CHIP HSIs, integrating home visiting into broader state health reform efforts, and aligning and coordinating home visiting efforts with new federal opportunities, such as reporting requirements for the CMS Child Core Set (i.e., Medicaid children’s health care quality measures). They also identified opportunities for federal agencies to continue to support state public insurance financing of home visiting services.
Considerations for Federal Agencies
- Provide ongoing education about home visiting program successes, technical assistance, and resources available to increase awareness and understanding among state Medicaid and CHIP, Title V MCH, and MIECHV program leaders and other key stakeholders about the array of federal Medicaid and CHIP authorities, policy levers, and strategies to support home visiting services.
One of the key challenges states and other key stakeholders identified was the need for ongoing education about state innovations and approaches to public insurance financing of home visiting services. While nearly half of states use Medicaid and CHIP to support home visiting services, ongoing education and technical assistance detailing what public insurance is available to cover home visiting and how to successfully braid public insurance with other federal, state and private financing streams could help states and key stakeholders develop strategies to maximize their home visiting programs. A deeper understanding of how to use Medicaid and CHIP to finance home visiting services could help states expand use of public insurance financing mechanisms.
- Stress the importance of integrating home visiting services into existing programs and services for parenting and pregnant women, children and their families, and align financing strategies so they support a comprehensive system.
Service integration is a key factor in improving the health and well-being of MCH populations. States are using public insurance to finance as many different types of services (e.g., screening, case management, and education) as possible to support home visiting. Interagency partnerships and collaboration have been key to service integration. States work across agencies to ensure that a wide range of services are available to Medicaid beneficiaries. Additionally, with multiple home visiting programs operating in states, streamlining enrollment applications for families is a priority. To promote service integration, states are moving towards health care models that treat both caregiver and child, and Medicaid agencies are beginning to develop financing strategies to support reimbursement of services in this area.[45] Home visiting programs provide an opportunity to develop financing strategies that support a two-generation model of care.
- Ensure that financing of home visiting programs, including the use of Medicaid and CHIP, integrates evidence-based programming and practices, such as the two-generation approach.
Home visiting models use the two-generation approach and home visitors are meeting with and providing services for both mother and baby. This requires new funding considerations and outcome measurement strategies to support home visiting models. Providing education about how to finance and bill home visiting programs can help states strengthen home visiting services that target both caregivers and their children. Education detailing how to measure outcomes when a home visitor is meeting with the whole family may clarify questions that states have about best practices around data monitoring.
- Coordinate home visiting measurement with the CMS Adult and Child Core set to foster alignment among public health and Medicaid performance and quality measures.
State participants identified coordinating data measurement as a key opportunity to help overcome some of the challenges around data collection and reporting, and to optimize new federal reporting requirements and opportunities under Medicaid. In particular, the Child and Adult Core sets are measures identified by CMS that have been shown to improve child and adult health outcomes. Starting in 2023, state Medicaid programs will be required to report on the measures set annually; currently reporting is voluntary.[46] These standardized measures present an opportunity for states, and in particular state Title V MCH program and MIECHV program leaders, to align their home visiting outcome measures with child and adult core measures under Medicaid. While there is no core measure for home visiting, the services provided may be represented by a measure in the core set. Alignment of these measures can help ensure home visiting services are considered as part of state child and adult health measure sets for Medicaid and identify the impact the programs have on health outcomes. Additionally, coordination with the Child Core set presents states with an opportunity to leverage integrated data systems that could help facilitate coordination of reporting to different agencies.
Considerations for States
- Integrate public insurance financing as part of state health reform efforts in Medicaid and CHIP, including strategies to move towards value-based payment (VBP).
State Medicaid health reform efforts are a key opportunity for states to maximize public insurance financing. Many state Medicaid agencies, like New York, are advancing VBP reforms providing an opportunity to use this strategy for public insurance financing of home visiting. At the meeting, state officials suggested considering bundled payment options for home visiting services. With an increase in VBP reforms and interest in alternative payment models, there is an opportunity for states to weave home visiting services into these broader health reform efforts. Because VBP and bundled payments are newer areas of focus for states, strategies, policy levers, and approaches for using these newer forms of payment and financing of home visiting services may be needed. In September of 2020, CMS released a letter to state Medicaid directors on Value-Based Care Opportunities in Medicaid detailing information on federal Medicaid regulatory authorities available to states and key considerations for states seeking to advance VBP, from level and scope of financial risk for payers and providers to assessment of delivery system readiness.[47] Additionally, the letter highlights various payment strategies states have used to advance value-based care like payment models built on fee-for-service architecture and episode-of-care payments. The letter presents additional opportunities for states to consider how to advance public insurance financing of home visiting as a part of value-based care efforts.
- Incorporate public insurance financing of home visiting services as part of state efforts to build and improve comprehensive, integrated systems of programs and services for women, children, and their families.
In order to promote and increase the use of public insurance financing of home visiting, there is a clear need to strengthen infrastructure support for home visiting. Through universal enrollment forms, partnerships with public health agencies, and by taking advantage of federal authorities, states are taking steps to strengthen infrastructure to support systems-based approaches to financing of home visiting programs that reach as many women and families as possible. Using a systems-wide approach involves multiple agencies and health systems that align and embed home visiting programs as part of coordinated care. This approach can help ensure the longevity and success of these programs. Public insurance is a key opportunity for states to strengthen systems, like early childhood, that include their home visiting networks and increase public health capacity to address social determinants of health. - Promote cross-sector partnerships as a critical element of public insurance financing of home visiting.
States involved in the federal-state discourse meeting had strong public/private and cross-sector partnerships. When states are considering increasing or restructuring their use of public insurance to finance home visiting services, it is essential to have strong working relationships across agencies and teams and engage executive leadership to help promote coordination. A strong cross sector partnership between state Medicaid, Title V, and MIECHV officials is integral to successfully using public insurance to finance home visiting. States also identified the private sector as a helpful partner in building and sustaining home visiting services. Bringing different agencies together to work on public insurance financing of home visiting services can strengthen overall systems and gain the political momentum to move the work forward. - Continue to advance financing strategies that promote the use of multiple federal and state financing streams, including Medicaid and CHIP, to support home visiting programs.
State participants underscored the importance of braiding different funding streams to help support home visiting programs. There are clear opportunities for states to expand home visiting services with public insurance financing and expand services like upstream interventions to help address social determinants of health. However, state officials underscored the need to ensure that public insurance financing considerations are part of a range of approaches to financing home visiting. State leaders spoke about how braiding funds, especially public insurance, is a key strategy to bolster home visiting and serve as many women, children, and families as much as possible.
Conclusion
Public insurance financing of home visiting programs is a complex issue that requires each state to decide what strategy works best and fits its specific needs. Numerous states, including those represented at this federal/state discourse meeting, are developing and implementing a range of innovative strategies and taking advantage of federal Medicaid and CHIP authorities to support home visiting services. Use of Medicaid and CHIP to support home visiting programs may be best advanced through education, technical assistance, resources, and efforts that promote cross-sector partnerships and collaboration among state Title V MCH programs, MIECHV program directors and state Medicaid agencies. Indeed, convening states to discuss different approaches and providing technical assistance to states may be the best approach to help them design home visiting programs that are supported by Medicaid and CHIP, among a variety of federal and state funding streams. Furthermore, public health crises (e.g., the opioid crisis and the COVID-19 pandemic) and other emergent issues can increase the need for home visiting services, but also provide new opportunities for financing and delivery of services to reach individuals through such strategies as telehealth. Home visiting programs provide valuable services, such as care coordination and referrals to social and community supports to MCH populations that states can leverage to continue work on social determinants of health. As states move forward with exploring public insurance financing, state budgets will be an important factor to consider when investing in home visiting services. Using public insurance to finance home visiting services is a key opportunity for states to improve the health and wellbeing of women and their families.
Appendix A: Key Informants
The National Academy for State Health Policy (NASHP) conducted key informant interviews to gather detailed information from subject matter experts and state officials on public insurance financing of home visiting services. Six subject matter experts and nine states were identified. State Medicaid, Title V, and MIECHV officials were invited to participate in the interviews to gather a wide range of perspectives. Key informant interviews with states and subject matter experts were scheduled for 30 minutes and conducted in the fall of 2019. Interviewees were specifically asked about opportunities, challenges, and barriers to public insurance financing of home visiting services and were given the opportunity to provide additional information on the topic.
- Medicaid, Title V, and MIECHV officials from the following states were interviewed. In some cases, we spoke with multiple state representatives.
- Alabama
- Colorado
- Kentucky
- Michigan
- Minnesota
- New Jersey
- New York
- South Carolina
- Texas
- Subject Matter Experts
- Jeanna Capito, Coordinator, Model Alliance
- Keith Fudge, Policy Program Manager, Urban Institute
- Kay Johnson, Consultant
- Sarah McGee, Chief Policy and Government Affairs Officer, Nurse Family Partnership
- Allison Meisch, Project Director, National Home Visiting Resource Center
- Christian Soura, Vice President, Policy and Finance, South Carolina Hospital Association
Appendix B: Federal/State Discourse Meeting on Public Insurance Financing of Home Visiting Services Participant List
State Officials
Bryan Amick Deputy Director, Office of Health Programs, South Carolina Department of Health and Human Services |
Laurel Aparicio Executive Director, Early Impact Virginia |
Linda Aragon Director, Division of Maternal, Child, and Adolescent Health Los Angeles County Department of Public Health |
Rachel Becker Special Assistant to the Secretary of Health and Human Resources Virginia Department of Health |
Stephen Cook Medical Director, Division of Medical and Dental Directors New York State Department of Health |
Margaret Geraghty Health Policy Analyst, Maternal, Infant, & Early Childhood Home Visiting Program Maryland Department of Health |
Benjamin Hazelton
|
Jordan Kennedy
|
Alexandra Loizias Division Chief, Innovation and Delivery System Reform Maryland Medicaid |
Dawn Reckinger Manager, Family Home Visiting Minnesota Department of Health |
Dawn Shanafelt Director, Division Maternal and Infant Health Michigan Department of Health and Human Services |
Christian Soura Vice President, Policy and Finance South Carolina Hospital Association |
Joanna Su Manager of Strategic Planning, Maternal, Infant, & Early Childhood Home Visiting Program at Governor’s Office of Early Childhood Development State of Illinois |
Federal Representatives
Josephine Ansah
Public Health Analyst, Division of Home Visiting and Early Childhood Systems |
Meg Barry Deputy Director, Division of State Coverage Programs Centers for Medicare & Medicaid Services |
Melissa Brodowski Deputy Director, Office of Early Childhood Development Administration for Children and Families |
Kelsi Feltz Public Health Analyst, Office of Policy and Planning Health Resources and Services Administration, Maternal and Child Health Bureau |
Rachel Herzfeldt-Kamprath Policy Analyst, Division of Home Visiting and Early Childhood Systems, Health Resources and Services Administration, Maternal and Child Health Bureau |
Amanda Innes Senior Advisor/Chief of Staff, Health Resources and Services Administration, Maternal and Child Health Bureau |
Kirsten Jensen Director, Division of Benefits and Coverage Centers for Medicare & Medicaid Services |
Michele Lawler Director, Title V Federal Program Health Resources and Services Administration, Maternal and Child Health Bureau |
Cynthia Phillips Director, Division of Home Visiting and Early Childhood Systems Health Resources Services Administration, Maternal and Child Health Bureau |
Ann Stock Public Health Advisor, Division of Home Visiting and Early Childhood Systems Health Resources and Services Administration, Maternal and Child Health Bureau |
Michael Warren Associate Administrator Health Resources and Services Administration, Maternal and Child Health Bureau |
Kristen Zycherman Coordinator, Maternal and Infant Health Initiatives Centers for Medicare & Medicaid Services |
National Organization Representatives
Emily Blanford Program Principal, Health Program National Conference of State Legislatures |
Jeanna Capito Consultant and Home Visiting Model Alliance Facilitator, Home Visiting Model Alliance |
Amy Haddad Director of Public Policy and Government Affairs, Association of Maternal & Child Health Programs |
Zach Laris Director of Federal Advocacy & Child Welfare Policy American Academy of Pediatrics |
Catriona MacDonald Executive Director, Association of State and Tribal Home Visiting Initiatives |
Sarah McGee Chief Policy and Government Affairs Officer, Nurse Family Partnership |
Mary Peniston Chief Program Officer, ChildFirst |
Kathy Pillow-Price Project Co-Director, Home Visiting Improvement Action Center Education Development Center |
Josh Prosser Policy Associate, Linchpin Strategies, LCC |
National Academy for State Health Policy Staff
Melissa Caminiti
Project Director (formerly with NASHP)
Eddy Fernandez
Research Analyst
Taylor Platt
Policy Associate
Karen VanLandeghem
Senior Program Director
Appendix C: Additional Resources on Financing of Home Visiting Programs
- Joint Informational Bulletin: Coverage of Maternal, Infant, and Early Childhood Home Visiting Services
- Medicaid Financing of Home Visiting Services for Women, Children, and Their Families
- Medicaid and Home Visiting: The State of States’ Approaches
- State Home Visiting Approaches Improve Early Childhood Outcomes and Systems
- Funding Home Visiting with a Pay for Outcomes Approach
- Financing Public Health Interventions through Pay for Success: South Carolina and the Nurse-Family Partnership Seek to Improve Maternal and Child Health through Pay for Success
- Home Visiting: Improving Outcomes for Children
- Fostering Social and Emotional Health through Pediatric Primary Care: A Blueprint for Leveraging Medicaid and CHIP to Finance Change
- Health Care Payment Learning & Action Network (HCPLAN): Alternative Payment Model (APM) Framework
- Health Affairs: A Roadmap for Driving High Performance in Alternative Payment Models
- American Academy of Pediatrics: Pediatric Accountable Care Organizations: Insight from Early Adopters
- CMS State Medicaid Director Letter on Value-Based Care Opportunities in Medicaid
- Developing Data Exchange Standards for MIECHV Home Visiting Programs
End Notes
- “Home Visiting.” Maternal and Child Health Bureau, March 4, 2020. https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview.
- Heather Zaveri, Andrew Burwick, and Erin Maher, “The Potential for Cost Savings from Home Visiting Due to Reductions in Child Maltreatment,” Casey Family Programs, April 2014, http://www.chapinhall.org/sites/default/files/documents/EBHV%20Cost%20Savings%20Brief.pdf.
- Michalopoulos, Charles, Kristen Faucetta, Anne Warren, and Robert Mitchell. Evidence on the Long-Term Effects of Home Visiting Programs: Laying the Groundwork for Long-Term Follow-Up in the Mother and Infant Home Visiting Program Evaluation (MIHOPE). OPRE Report 2017-73. Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. https://files.eric.ed.gov/fulltext/ED579153.pdf
- “Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program: Background and Funding.” Congressional Research Service, November 21, 2018. https://fas.org/sgp/crs/misc/R43930.pdf.
- “Home Visiting.” Maternal and Child Health Bureau, March 4, 2020. https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview.
- National Home Visiting Resource Center. 2019 Home visiting yearbook. James Bell Associates and Urban Institute. 2019. https://live-nhvrc.pantheonsite.io/wp-content/uploads/NHVRC_Yearbook_Summary_2019_FINAL.pdf
- The Maternal, Infant, and Early Childhood Home Visiting Program Partnering with Parents to Help Children Succeed, The Maternal, Infant, and
- Early Childhood Home Visiting Program Partnering with Parents to Help Children Succeed (2020). Retrieved from
- https://mchb.hrsa.gov/sites/default/files/mchb/MaternalChildHealthInitiatives/HomeVisiting/pdf/programbrief.pdf
- Vikki Wachino and James Macrae, “Coverage of Maternal, Infant, and Early Childhood Home Visiting Services,” CMCS and HRSA Joint Information Bulletin, March 2016, https://www.medicaid.gov/federal-policy-guidance/downloads/cib-03-02-16.pdf.
- Johnson, Kay. Medicaid Financing for Home Visiting: The State of States’ Approaches. Johnson Group Consulting, Inc. 2019. https://ccf.georgetown.edu/wp-content/uploads/2019/01/Medicaid-and-Home-Visiting.pdf
- Normile, Becky, Karen VanLandeghem, and Alex King. “Medicaid Financing of Home Visiting Services for Women, Children, and Their Families.” The National Academy for State Health Policy, August 2017. https://nashp.org/wp-content/uploads/2017/09/Home-Visiting-Brief.pdf
- Managed care rate setting, Managed care rate setting § (n.d.). https://www.macpac.gov/subtopic/managed-care-rate-setting/.
- Ibid
- 2019-2020 Medicaid Managed Care Rate Development Guide, 2019-2020 Medicaid Managed Care Rate Development Guide § (2019). https://www.medicaid.gov/Medicaid/downloads/2019-2020-medicaid-rate-guide.pdf.
- Herzfeldt-Kamprath, Rachel, Maura Calsyn, and Thomas Huelskoetter. “Medicaid and Home Visiting: Best Practices from States.” Center for American Progress, January 25, 2017. https://www.americanprogress.org/issues/early-childhood/reports/2017/01/25/297160/medicaid-and-home-visiting/.
- “Home Visiting.” Maternal and Child Health Bureau, March 4, 2020. https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview.
- Sandstrom, Heather, Sarah Benatar, Rebecca Peters, Devon Genua, Amelia Coffey, Cary Lou, Shirley Adelstein, et al. “Home Visiting Career
- Trajectories.” Urban Institute, February 2020.
- https://www.urban.org/sites/default/files/publication/101641/home_visiting_career_trajectories_0.pdf.
- Vikki Wachino. “Maternal Depression Screening and Treatment: A Critical Role for Medicaid
- in the Care of Mothers and Children,” CMS, May 2016, https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf
- “Home Visiting.” Maternal and Child Health Bureau, March 4, 2020. https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview.
- 42 CFR § 431.958
- 42 CFR § 431.51
- SMD # 16-005 Re: Clarifying “Free Choice of Provider” Requirement in Conjunction with State Authority to Take Action against Medicaid Providers, SMD # 16-005 Re: Clarifying “Free Choice of Provider” Requirement in Conjunction with State Authority to Take Action against Medicaid Providers § (2016). https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/SMD16005.pdf.
- Johnson, Kay. Medicaid Financing for Home Visiting: The State of States’ Approaches. Johnson Group Consulting, Inc. 2019. https://ccf.georgetown.edu/wp-content/uploads/2019/01/Medicaid-and-Home-Visiting.pdf
- Medicaid. “About Section 1115 Demonstrations.” About Section 1115 Demonstrations, n.d.
- https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html.
- Normile, Becky, Karen VanLandeghem, and Alex King. “Medicaid Financing of Home Visiting Services for Women, Children, and Their Families.” The National Academy for State Health Policy, August 2017. https://nashp.org/wp-content/uploads/2017/09/Home-Visiting-Brief.pdf
- Medicaid. “About Section 1115 Demonstrations.” About Section 1115 Demonstrations, n.d.
- https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations/index.html.
- “Medicaid Benefits: Targeted Case Management,” Kaiser Commission on Medicaid and the Uninsured, accessed March 2017, http://kff.org/ medicaid/state-indicator/targeted-case-management.
- Sara Rosenbaum et al, “Medicaid and Case Management to Promote Healthy Child Development,” The Commonwealth Fund, June 2009, https://publichealth.gwu.edu/departments/healthpolicy/DHP_Publications/pub_uploads/dhpPublication_FB044708-5056-9D20- 3D1C4A53DFA85EC7.pdf.
- Medicaid Coverage of April 2017 Pregnancy and Perinatal Benefits,” Kaiser Family Foundation, http://files.kff.org/attachment/Report-Medicaid-Coverage-of-Pregnancy-and-Perinatal-Benefits
- . “Maternal, Infant, and Early Childhood Home Visiting Program in Kentucky – Competitive Application,” Kentucky Department of Public Health, submitted to the U.S. Department of Health and Human Services June 28, 2011,https://healthcarereform.ky.gov/grants/Documents/Maternal,%20Infant%20and%20Early%20Childhood%20Home%20Visit%20Program%20in%20Kentucky.pdf
- Normile, Becky, Karen VanLandeghem, and Alex King. “Medicaid Financing of Home Visiting Services for Women, Children, and Their Families.” The National Academy for State Health Policy, August 2017. https://nashp.org/wp-content/uploads/2017/09/Home-Visiting-Brief.pdf
- “Michigan Home Visiting Report: How Home Visiting Supports Michigan Families ,” 2017. https://www.michigan.gov/documents/homevisiting/Home_Visiting_Initiative_Report_2017_637278_7.pdf.
- Ibid
- Johnson, Kay. Medicaid Financing for Home Visiting: The State of States’ Approaches. Johnson Group Consulting, Inc. 2019. https://ccf.georgetown.edu/wp-content/uploads/2019/01/Medicaid-and-Home-Visiting.pdf
- Home Visiting Services Pilot. Maryland Department of Health. Accessed April 6, 2020. https://mmcp.health.maryland.gov/Pages/Home-Visiting-Services-Pilot.aspx.
- Frequently Asked Questions (FAQs) Health Services Initiative, Frequently Asked Questions (FAQs) Health Services Initiative § (2017).
- https://www.medicaid.gov/sites/default/files/federal-policy-guidance/downloads/faq11217.pdf.
- “About: SafeCare Arkansas.” Stronger Families Brighter Futures, n.d. https://www.arhomevisiting.org/modelname/safecare-arkansas/.
- State Plan Amendment Approval AR-16-0002-CHIP, State Plan Amendment Approval AR-16-0002-CHIP § (2016).
- https://www.medicaid.gov/sites/default/files/CHIP/Downloads/AR/AR-16-0002-CHIP.pdf.
- “Section 1915(b) Waiver Proposal for MCO, PIHP, PAHP, PCCM Programs and FFS Selective Contracting Programs,” South Carolina Department of Health and Human Services, December 2015, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/Downloads/SC_Enhanced-Prenatal-Postpartum-Home-Visitation-Managed-Care.pdf
- “South Carolina Nurse-Family Partnership Pay for Success Project,” South Carolina Department of Health and Human Services, 2016, https://www.scdhhs.gov/sites/default/files/NFP%20PFS%20Fact%20Sheet%20scdhhs.pdf.
- “Value-Based Payment.” MACPAC. Medicaid and CHIP Payment and Access Commission, March 18, 2020. https://www.macpac.gov/subtopic/value-based-purchasing/.
- Maternal and Infant Health Care Delivery Models and Value-Based Payment Approaches: Key Findings From an Environmental Scan , Maternal and Infant Health Care Delivery Models and Value-Based Payment Approaches: Key Findings From an Environmental Scan § (2018). https://www.medicaid.gov/state-resource-center/innovation-accelerator-program/iap-downloads/functional-areas/iap-maternal-health-factsheet.pdf.
- Ibid
- “New York State Medicaid Redesign Team Waiver .” 1115 Research and Demonstration Waiver, November 27, 2019. https://www.health.ny.gov/health_care/medicaid/redesign/dsrip/2019/docs/formal_amendment_req.pdf.
- “Department of Health.” First 1000 Days on Medicaid Initiative. Accessed April 6, 2020. https://www.health.ny.gov/health_care/medicaid/redesign/first_1000.htm.
- Pierce-Wrobel, Clare, and Katie Green. “To Help Fix The Maternal Health Crisis, Look To Value-Based Payment.” Health Affairs Blog, July 16, 2019. https://www.healthaffairs.org/do/10.1377/hblog20190711.816632/full/.
- “Children’s Health Care Quality Measures,” 2020. https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-and-child-health-care-quality-measures/childrens-health-care-quality-measures/index.html.
- Anne Marie Costello and Brad Smith. “Value-Based Care Opportunities in Medicaid.” Center for Medicaid and CHIP Services and Center for Medicare and Medicaid Innovation. September 2020. https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/smd20004.pdf
Acknowledgments: The National Academy for State Health Policy thanks state officials who participated in key informant interviews and to those who attended the Federal/State Discourse Meeting, and to colleagues Cynthia Phillips, Amanda Innes, Ann Stock, Josephine Ansah, and Kelsi Feltz of the Health Resources and Services Administration, as well as colleagues at the Centers for Medicare & Medicaid Services for their invaluable feedback and guidance. This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
Three States’ Strategies to Improve Behavioral Health Services Delivery through Medicaid Accountable Care Programs
/in Policy Colorado, Minnesota, Rhode Island Featured News Home, Reports Accountable Health, Care Coordination, CHIP, Chronic and Complex Populations, Cost, Payment, and Delivery Reform, Health Equity, Integrated Care for Children, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Quality and Measurement, Quality and Measurement /by Neva KayeIn recent years, Colorado, Minnesota, and Rhode Island began using accountable care programs to improve delivery of behavioral health services. Already, the programs have produced improvements – Colorado reports an increase in the percentage of Medicaid enrollees receiving behavioral health services and Minnesota’s accountable care organization (ACO) providers have performed better than other clinics in screening adolescents for mental health issues. This report examines these states’ policies and experiences in using accountable care programs to improve delivery of behavioral health care.
Background
Medicaid is the largest payer of behavioral health care (mental health and substance use disorder) in the United States.[1] In addition, studies show that behavioral health conditions contribute to a greater cost to treat than other medical conditions.[2] There are great disparities in health outcomes for people with behavioral health diagnoses,[3] individuals with behavioral health conditions are sicker and die younger than those without such conditions. As states grapple with unprecedented budget crises and increased demand for behavioral health services due to the COVID-19 pandemic, there are incentives for them to change how behavioral health care is delivered.
In an accountable care program, groups of providers (called ACOs) share responsibility for the quality of care, health outcomes, and costs for a defined population. These programs emphasize primary care, care coordination and integration, and value-based payment. Payment depends on the ACO’s performance on defined metrics.
There is broad recognition that integrating behavioral and physical health care, and identifying and treating behavioral health conditions early can lead to improved outcomes.[4] States also face severe behavioral health workforce shortages, especially in lower-income areas — where many of those served by the Medicaid program live.[5]
As a result, states have for many years sought to reform their delivery systems to improve identification and treatment of behavioral health conditions, better integrate behavioral and physical health, and increase Medicaid enrollees’ access to behavioral health care. Many of these previous efforts were based in managed care or on a patient-centered medical home (PCMH) model.
A decade ago, state Medicaid agencies began to implement accountable care programs. In early 2020, the National Academy for State Health Policy identified eight states that had begun to use their accountable care programs to improve their delivery of behavioral health care: Colorado, Maine, Massachusetts, Minnesota, New Jersey, Oregon, Rhode Island, and Vermont. The ACOs participating in these programs focus on coordination and integration of care and provide an infrastructure to improve behavioral health services that, due to their focus on primary care, may prove particularly useful for advancing behavioral health integration.
The pandemic is already causing some states to delay delivery system reforms. However, over the longer term, the pandemic may cause more states to turn to accountable care to help them manage behavioral health services. In recent months, state Medicaid officials have had to focus their attention on ensuring that Medicaid enrollees receive the care they need, leaving little time to develop new reforms. Large state budget shortfalls are also projected,[6] which are likely to lead states to implement cost containment strategies. States may turn to accountable care programs, which hold ACOs and their affiliated providers accountable for cost, quality, and health outcomes, as a way to provide quality services while containing cost. The pandemic is also likely to create increased need for behavioral health services.[7] According to a July 2020 Kaiser Family Foundation poll, more than half of the adults reported that “stress and worry related to the pandemic has had a negative impact on their mental health.”[8] State Medicaid agencies may, ultimately, turn to accountable care to address the combined effect of decreased state funding and increased need for behavioral health services.
This report outlines the program policies, implementation experience, and lessons learned in three states that have all used accountable care to improve behavioral health care and contain cost.
How Colorado, Minnesota, and Rhode Island Structure their Programs
The three states structured their accountable care programs in different ways.
Colorado’s Regional Accountable Entities
This report uses “ACO” when describing more than one state’s accountable care organization, as each state has a unique name for its ACO.
- Colorado contracts with regional accountable entities (RAEs);
- Minnesota contracts with Integrated Health Partnerships (IHPs); and
- Rhode Island certifies accountable entities (AEs).
Colorado began its accountable care program in 2011, but the state did not emphasize behavioral health care in the program until it launched the second phase in July 2018. At that point, Colorado folded its specialized managed care program for behavioral health services into its accountable care program. Since 2018, Colorado has contracted directly with seven regional accountable entities (RAEs). Colorado assigns almost all Medicaid enrollees to a RAE (representing about 97 percent of Colorado’s 1.3 million Medicaid enrollees in July 2020).[9] RAEs support a local network of primary care medical providers (PCMPs), deliver behavioral health services, coordinate members’ care across systems, and are accountable for the cost and quality of care delivered to Medicaid members.
RAEs are paid through a combination of per member per month (PMPM) administrative payments, capitation, and incentive payments. RAEs receive $15.50 PMPM as an administrative payment. The Medicaid agency withholds $4 of each $15.50 to fund the Key Performance Indicator (KPI) payments. The Medicaid agency assigns each of seven KPI metrics a specific PMPM amount, and if a RAE produces sufficient improvement on the measure, it receives a payment based on the PMPM amount assigned to the measure. KPI payments are calculated and distributed each quarter. Unearned incentive payments are used to fund a challenge pool that is distributed based on performance in pursuing specified state policy priorities (e.g., collaboration with institutes of mental diseases or achieving progress on other performance metrics. RAEs also receive capitation payments for behavioral health services and are eligible to receive incentives tied to performance on a set of behavioral health measures. These payments are referred to as behavioral health incentive payments.
Both PCMPs and behavioral health providers must contract with a RAE in order to serve Medicaid enrollees. PCMPs receive fee-for-service payments from the Medicaid agency and administrative and incentive payments from the RAEs. Behavioral health providers contract with the RAEs and receive all payments directly from their RAE.
Minnesota’s Integrated Health Partnerships
Minnesota began its accountable care program in 2013. The state considered behavioral health when designing the initial phase of its program, but strengthened its behavioral health focus in Phase 2 of the program (IHP 2.0), which launched in January 2018. As of June 2020, Minnesota Medicaid contracts with 26 Integrated Health Partnerships (IHPs) that, together, serve 430,000 Medicaid and MinnesotaCare (Minnesota’s basic health plan) enrollees. IHPs are provider organizations. They and their associated providers receive payment for services from either the MCOs or the Medicaid fee-for-service system.
In addition, IHPs are paid through one of two payment models.
- Track 1 is intended for small, independent provider systems, specialty health care groups that coordinate care for specific groups of individuals, or a specific major portion of services (including primary care), or other systems unable to take on financial risk.
- Track 2 is only open to IHPs that serve more than 2,000 members and that are able to take on upside and downside risk (i.e., share in both savings and losses).
All IHPs (both tracks) receive a clinical and social risk-adjusted monthly population-based payment. In exchange, all IHPs must develop and implement specific health initiatives that address certain social risk factors that their patient populations are facing and achieve satisfactory performance on a set of quality and performance measures in order to continue to participate in the program. Both the initiative itself and the measures are negotiated between the individual IHP and the Medicaid agency. IHPs that participate under Track 2 also share in both savings and losses.
Savings and losses are calculated by comparing the actual total cost of care (TCOC) of the members attributed to the IHP with the members’ projected TCOC absent the IHP. If actual TCOC is less than projected, the difference is savings; if actual is more than projected, the difference is a loss. TCOC is defined to include the cost of providing most services. (See page 54 of Minnesota’s Integrated Health Partnerships Contract for a list of included services.)
The calculation of the amount of savings to be paid to the IHP or the amount of loss to be paid to the agency is based on multiple factors. First, the IHP is only eligible to share in any amount of savings or losses that fall within a negotiated risk corridor (e.g., 6 percent). All profit or loss outside the corridor belongs solely to the agency. The exact share of the amount within the risk corridor (e.g., the available savings) each IHP receives depends on two factors — the savings split it has negotiated with the agency and its performance in three domains (care quality, health information exchange, and alerting exchange).
But the share of losses depends only on the losses split negotiated with the agency and not its performance. The standard split is 50/50, meaning that IHPs can earn up to 50 percent of available savings and will pay 50 percent of available losses. But an IHP can secure a different split by entering into an accountable partnership with a community partner (e.g., a community mental health center [CMHC]) and negotiating a different split with the Medicaid agency — typically IHPs with an accountable partnership agree to take up to 70 percent of the available savings and pay 35 percent of available losses.
Rhode Island’s Accountable Entities
Rhode Island Medicaid began piloting its accountable care program in 2016 and launched its full program in July 2018 when it certified six comprehensive accountable entities (AEs). The Medicaid agency does not contract directly with its certified AEs. Instead, it requires Medicaid MCOs to contract with the AEs (and AEs to contract with MCOs). Each AE and MCO negotiate their own payment models within parameters set by the state. State officials shared that they have become more prescriptive on payment model as their and other stakeholders’ experience has grown and as the number of AEs (and thus the number of contracts that must be negotiated between MCOs and AEs and overseen by the state) grows. Both MCOs and AEs agreed on the need for increased standardization. Currently, all payment models must be based in TCOC calculated according to state requirements and MCOs must share up to 50 percent of any savings with AEs. AEs may accept shared losses if the Office of the Health Insurance Commissioner, which licenses commercial health plans, has determined that the AE is qualified to accept that risk. The amount of savings awarded to an AE must depend on the AE’s performance on at least three measures selected from a common measure set. State payment model parameters also govern how people are attributed to AEs.
In 2016, the Centers for Medicare & Medicaid (CMS) authorized the creation of AEs through approval of an amendment to Rhode Island’s Section 1115 Comprehensive Demonstration waiver. This amendment also authorized the state to create the Medicaid Infrastructure Incentive Program (MIIP) as a Designated State Health Program (DSHP). This designation, which CMS stopped awarding in 2017, authorized the state to receive, over the five-year period of November 2016 to December 2020, up to $129.8 million in federal funding to match state expenditures to support AE infrastructure development. In program Year 3, MCOs may earn up to $1.60 PMPM for each member attributed to a qualified AE. AEs may earn up to $8.44 PMPM by developing and completing projects that support the state’s goals, including those related to behavioral health. Actual payment is based on the achievement of performance milestones, most of which are negotiated between each AE and MCO, subject to state approval.[10]
Why States Included Behavioral Health in Accountable Care
“[In Rhode Island] managed care needed to evolve to be responsible for the needs of individuals with chronic conditions and needs. This pushed managed care to be more holistic across the board.”
Colorado, Minnesota, and Rhode Island chose to include behavioral health in their accountable care programs in order to improve chronic care, increase behavioral health integration, and produce cost savings. Officials from both Colorado and Rhode Island reported that that their new accountable care programs built on their previous efforts to strengthen primary care and better integrate behavioral health into primary care. Rhode Island officials explained that the primary care-centered approach worked well for individuals with moderate or low behavioral health needs, but the “needs of the other end of continuum also need to be considered.” Rhode Island believed that the structure of the accountable care program gave the CMHCs, which can better serve high need individuals, more opportunity to leverage their skills and strengths to be a resource for primary care. Eventually, this state would like to bring primary care to CMHCs in at least some of their AEs.
“Due to high spending for behavioral health on high utilizers, there is value in homing in on integrating physical and behavioral health from a savings perspective.” – Colorado official
Both Colorado and Rhode Island emphasize that behavioral health providers are well-positioned to engage patients with complex needs. Colorado officials also believe that RAEs’ structure, which makes them responsible for both primary and behavioral health care, would increase integration between the two types of services. Officials stated that the care coordination provided by CMHCs under its managed behavioral health program was strong. But they believed that folding the behavioral health program (and CMHCs) into their accountable care program fostered whole person care coordination for those with complex needs. They believed that increased integration and more holistic care coordination would lead to less fragmentation of care, create economies of scale, and, in turn, produce cost savings.
Colorado had also hoped that the RAEs would increase access to behavioral health services. This state has seen an increase in the proportion of Medicaid enrollees who receive one or more behavioral health services, and stakeholders are reporting that access and choice are both stronger.
How States Improve Behavioral Health through Accountable Care
All three states through their ACO contracts (Colorado and Minnesota) or certification standards (Rhode Island), consider performance on behavioral health measures in ACO payments. All three states also considered behavioral health in the performance requirements they created for their ACOs regarding network adequacy, care coordination and integration, and health information technology (HIT) supports. One or more of these states also called out behavioral health in the requirements they established in many other areas of performance.
Attribution
Attribution is the process used to identify the members of the defined population for which the ACO is accountable. All attribution processes consider where the patient has obtained care in the past. All three states featured in this brief first attribute Medicaid enrollees to a primary care provider (PCP) or a subset of PCPs who have met state-established qualifications. These states then consider each ACO to be “accountable” for the enrollees attributed to the providers affiliated with the ACO. All three states attribute enrollees with behavioral health conditions to a primary care provider, but only Minnesota currently considers behavioral health in that process. The first step of Minnesota’s process is to attribute Medicaid enrollees who have received services from a behavioral health home (or health care home) to the IHP with which that provider is affiliated.
Rhode Island had implemented a similar policy at program launch but now considers only primary care in attribution. Officials reported that they made this change because they determined that including attribution to an Integrated Health Home as the first step was difficult and time consuming. This, along with member churn impacted the state’s ability to confidently collect performance data. Additionally, Rhode Island found that many of the people served by integrated health homes were engaged in primary care with a separate provider.
Payment Models
As previously described, Colorado, Minnesota, and Rhode Island have each created a unique payment model for their ACOs. All three states, however, consider behavioral health performance in ACO payments and have established policies that foster consideration of behavioral health performance in payments to individual providers.
ACO Payment
Payment is considered to be the driving force to ensure ACO accountability for performance. All three states have tied ACO payment to behavioral health performance. Colorado’s RAEs may earn two types of incentive payments for performance. A RAE may earn incentives of up to $4 PMPM in key performance indicator (KPI) payments, which are primarily tied to the performance of the PCMP network. The RAE may also earn up to 5 percent of its behavioral health capitation rate (about $30 million) in behavioral health incentive (BHI) payments, which are primarily tied to the performance of the behavioral health network.
In both Minnesota and Rhode Island, ACOs may earn a share of the savings they produce — and are sometimes required to also share in any losses. Both of these states calculate savings and losses using a TCOC methodology. Both also include behavioral health services in the TCOC calculation, and Minnesota considers behavioral health services when calculating the monthly population-based payment that each of its IHPs also receives.
Regardless of their specific ACO payment model, all three states tie ACO payment to performance on a set of metrics that includes behavioral health measures, along with measures of other types of performance. In Colorado, performance on the metrics governs the amount of the incentives the RAEs earn. In Minnesota, performance on the metrics governs whether Track 1 IHPs may continue to participate in the program and whether Track 2 IHPs earn the full portion of their contracted share of any savings they produce. In Rhode Island, performance on the metrics governs what portion of savings are paid to the AE and how much the MCO may retain (and for those AEs that have been approved to accept downside risk, what portion of the losses they are required to pay to the MCO).
“Measures [in Rhode Island] were shaped by high-level goals of the organization and we wanted to make sure that there are mechanisms for balanced, useful data.”
There is little commonality between the behavioral health measures these states chose to factor into payment (Table 1). Only one measure is used by all three states – follow-up appointments within X days after an inpatient hospital discharge for a mental health condition, although even on this measure, states have made different choices as to when to specify seven-day follow-up and when to specify 30-day follow-up. Although there was little commonality between the specific measures used, there was some commonality regarding the domains to be measured. All three states included measures of engagement and follow-up.
When asked why they chose their specific measures, state interviewees uniformly reported that the choices were based on their goals for the program and stakeholder input. They also reported that the choices were informed by previous efforts.
- Rhode Island, for example, drew its measures from a common measure set created as part of the state’s State Innovation Model (SIM) initiative.
- Colorado emphasized that it considered areas that it knew had “room for improvement” and used measurement to create incentives for the RAEs to change that part of the system. For example, the state tied payment to “follow-up after a positive depression screen” in order to incent behavioral health and primary care integration. Further, Colorado sought to align its behavioral health (BHI) and primary care (KPI) payments to incentivize the same behavior across the program. As one official explained, “behavioral health is not in a silo, and requires the engagement of physical health as well.”
- Finally, this measure set is not static, Minnesota, for example, is currently phasing out its medication measures.
Table 1: Behavioral Health Measures that Factor into ACO Payments
Colorado | Minnesota | Rhode Island | |
Screening and Assessment | |||
Screening for depression and follow-up plan | Some IHPs* | Optional | |
Behavioral health screening or assessment for children in the foster care system | BHI | ||
Developmental screening in first three years of life | Optional | ||
Engagement and Follow-up | |||
Initiation and engagement of alcohol and other drug abuse or dependence (AOD) treatment | Required | ||
Engagement in outpatient substance use disorder (SUD) treatment | BHI | ||
Behavioral health engagement: Percentage of members who received a behavioral health service delivered either in primary care settings or under the capitated behavioral health benefit within a 12-month evaluation period | KPI | ||
Follow-up appointment within 7 or 30 days After an inpatient hospital discharge for a mental health condition | BHI; 7-day | Track 1: 7- or 30-day
Track 2: 30-day |
Required, opt for 7- or 30-day |
Follow-up appointment within 7 days after an emergency department (ED) visit for a substance use disorder | BHI | ||
Follow-up after a positive depression screen | BHI | Some IHPs* | |
Medication | |||
Antidepressant medication management: acute and continuous | Required | ||
Adherence to antipsychotics for individuals with schizophrenia | Required |
Acronyms: BHI=behavioral health incentive payment; KPI=key performance indicator payment; IHP=Integrated Health Partnership.
*The measure is used if it is appropriate to the topic of the health intervention that the IHP and Minnesota Medicaid jointly select.
Colorado’s RAEs have increased the percent of Medicaid enrollees who receive behavioral health care.
To date, only Colorado has published a summary of ACO performance on the measures that factor into incentive payments. This state has seen some positive results. On the primary care side, payment is tied to behavioral health engagement. During the first year of program operation, the RAEs produced almost a two-percentage point increase in this metric. On the behavioral health side, Colorado established incentives for performance on five measures.
During the program’s first year of operation:
- All seven RAEs met performance improvement goals for engagement in outpatient SUD treatment and follow-up after a positive depression screening;
- Five met the goal for behavioral health assessment for children in the foster care system; and
- Four met the goals for follow-up from mental health inpatient stays and SUD emergency room visits.[11]
Although not yet complete, Rhode Island is conducting an evaluation of its program which, when complete, will shed more light on its program’s impact on behavioral health care.
Minnesota officials report that IHPs perform above average when compared to clinics and/or systems that are not IHPs, on many quality measures, including those related to diabetes, asthma, and vascular care. In terms of behavioral health metrics, IHPs perform better than non-IHPs on ensuring adolescents are screened for mental health issues. Additionally, those IHPs with health interventions with a behavioral health focus have seen some positive results, including high levels of relative improvement across years.
Payment to Individual Providers
Colorado and Rhode Island both sought to ensure that the individual providers, including behavioral health providers, affiliated with their ACOs would benefit from performance payments earned by the ACO. Colorado explicitly requires its RAEs to share any incentive payments the RAE receives with the providers who form the RAE’s health neighborhood, which consists of the providers (including behavioral health providers) and facilities that work with an individual’s PCMP to meet all of the person’s health needs. RAEs are also required to report all payment arrangements, including those with behavioral health providers to the Medicaid agency. Rhode Island does not require its AEs to share savings, but it does require the AEs to have documented relationships with behavioral health provider partners to meet their patients’ needs, and Rhode Island Medicaid envisions that some of those relationships will include shared savings. It also requires the AEs to share 10 percent of any incentive pool payments they receive with a partner organization, which may be a behavioral health provider.
Minnesota encourages its IHPs to implement accountable care partnerships by potentially rewarding the IHP with more favorable financial arrangements. For example, instead of receiving 50 percent of any savings, the IHP might receive 70 percent. An IHP can use this mechanism to also reduce the share of any losses that it must pay, and Medicaid officials report that it is this attribute that is often most attractive to the IHP. The financial arrangements are negotiated with each IHP. Minnesota offered an example of a potential partnership between an IHP and a CMHC. The CMHC agrees to provide behavioral health services to a targeted set of patients who screen positive for a behavioral health need. IHP-affiliated providers will screen patients, refer those who screen positive to the CMHC, and the CMHC will provide any needed services and ‘close the loop’ by providing information back to the referring provider. Minnesota Medicaid also negotiates the specific measures that will be used to judge the success of the partnership. In this case, that might include the number of patients that were screened for behavioral health needs divided by the total number of patients, or it could also include the total patients who received services divided by the total patients referred. Although there is no requirement that partners be paid, eligibility for a more favorable risk arrangement depends on several factors that encourage payment, including how well the partners are working together.
Finally, when it launched its accountable care program, Colorado Medicaid began directly paying PCMPs (i.e., primary care providers) for short-term behavioral health treatment (up to six visits) on a fee-for-service basis. Other behavioral health services are paid for by the RAEs. Colorado Medicaid had anticipated that this change would foster behavioral health integration and support then-existing partnerships between some federally qualified health centers (FQHCs) and CMHCs. As expected, this policy did improve access for patients with more mild behavioral health conditions. However, some FQHCs chose to withdraw from the partnerships and hire staff to provide the short-term services. Colorado Medicaid also found the policy more difficult to implement than anticipated, as the agency had to adjust the payments it made to the RAEs for behavioral health services to reflect that payment for some short-term services that would now be made by the agency.
ACO Performance Requirements
Colorado, Minnesota, and Rhode Island all complemented their payment reforms with performance requirements to help ensure that their ACOs were prepared to deliver accountable care and that savings would be produced by improving care rather than curtailing access. These three states all chose to address behavioral health in their ACO performance requirements governing provider network composition and access to services, care coordination, and health information technology.
Table 2: Performance Area Requirements
Performance Area | Colorado | Minnesota | Rhode Island |
Network and access to services | √ | √ | √ |
Care coordination | √ | √ | √ |
Health information technology | √ | √ | √ |
Provider support | √ | √ | |
Quality | √ | √ |
Network Composition and Access to Behavioral Health Services
All three states required their ACOs to include at least some behavioral health providers among their affiliated providers, although only two required contracts. Colorado required its RAEs to create a statewide behavioral health network and offer contracts to CMHCs and substance use disorder (SUD) clinics. Similarly, Minnesota’s IHPs must contract with CMHCs “to the extent possible,” and each AE in Rhode Island must demonstrate that they have sufficient partnerships with behavioral health providers to provide the population that the AE plans to serve with access to a range of treatment options that represent a continuum of care. Rhode Island officials reported that in the early years of their program, they required the AEs to partner with CMHCs. Now that many of the AE/CMHC partnerships are well-established, this performance standard has been broadened to count partnerships with all types of behavioral health providers, not just CMHCs. Rhode Island has broadened the requirement to include all behavioral health providers. These three states also established other performance expectations. For example, Rhode Island requires each AE to include a representative of a community-based behavioral health provider within its governance structure.
“Care coordination…with CMHCs was strong, but with the [primary care and behavioral health] combination there is more whole-person care coordination…”
Colorado officials reported that access to behavioral health services increased because those providers who had been delivering care through the specialty managed care program continued to deliver care as part of the RAEs’ networks, but the RAEs had expanded their independent provider network as well. Officials viewed this to be an overall positive outcome because both traditional providers (e.g., CMHCs) and independent providers who had not previously treated Medicaid enrollees were needed to meet the current Medicaid population’s full range of needs. However, some RAEs, especially those that hadn’t established some utilization review requirements, found that utilization of expensive services, such as inpatient services, increased. These RAEs are now working to ensure that the right utilization management is in place, and one aspect of that work is to assess whom the independent provider networks are serving and consider if that is the best place for those enrollees to receive care.
Care Coordination and Population Health Management
One of the hallmarks of accountable care is ensuring that patients’ needs are systematically identified and addressed, and that care is coordinated across systems and providers. All three states established policies for care coordination that addressed behavioral health issues.
- Minnesota used its IHP selection process to establish the expectation that IHPs should screen patients for behavioral health and chemical dependency conditions and that care coordination should feature “integration of medical/behavioral-chemical/social service community care coordination and planning.”
- Colorado’s contract with its RAEs defines care coordination to include coordination of behavioral health needs and then includes numerous requirements for care coordination. Because this state has also tasked its RAEs with delivering behavioral health care, it has created requirements for that system, including requiring RAEs to fund intensive case management from savings.
- Rhode Island’s certification standards require AE’s to have policies and procedures in place that support integration of physical, behavioral, and social supports.
“The important piece is that the expansion of the independent provider network [in Colorado] reshaped the landscape of services being performed while CMHCs remained in the game…”
Colorado and Rhode Island also created requirements to ensure that behavioral health was addressed at the population level by requiring their ACOs to prepare population health plans that address behavioral health issues. Rhode Island also includes requirements designed to ensure that the plan guides each AE’s population health management activities, including behavioral health integration that considers risk factors for poor behavioral (as well as physical) health outcomes.
Health Information Technology (HIT)
Data is key to systematically identifying and managing a population’s health needs, identifying gaps in care, and measuring health outcomes. Colorado, Minnesota, and Rhode Island took slightly different approaches to ensuring that providers had, and could use, data to improve delivery of behavioral health services.
- Minnesota provides clinical data, including behavioral health claims data, to IHPs on a monthly basis and requires IHPs to use the data to improve performance.
- Colorado also provides claims data to the RAEs and, in addition, emphasizes the use of electronic care coordination and other analytic tools. This state required each RAE to have a care coordination tool to help PCMPs and other providers, including behavioral health providers, coordinate care — and also required that the tool had to support “HIPAA and 42 CFR Part 2 compliant data sharing.” RAEs were additionally required to have other data analytic tools and to support providers use of the tools.
- Rhode Island established requirements for using analytic tools (decision-support tools) and is developing a dashboard for AEs that provides information about their performance on quality measures. In addition, this state requires AEs to include behavioral health provider contacts in patient registries.
Provider Support
“More [technical assistance] was needed in the beginning to help behavioral health providers understand workflow and [payment] models.”
Shifting to a new delivery and payment model can be difficult, even when providers voluntarily shift. Changing providers’ approaches to delivering care, including behavioral health care, to enable them to thrive under a new system can be particularly difficult. Colorado and Rhode Island both addressed these concerns in their accountable care programs but took very different approaches.
Colorado required its RAEs to provide the support. Each RAE was required to prepare and implement a provider support plan that addressed the RAE’s plan to help providers work toward behavioral health integration. Under these plans, RAEs offer providers access to care coordinators, practice transformation coaches, and ongoing training. They also offer in-person coaching and online support, including access to tools and resources for provider use.
Rhode Island’s MIIP, which is funded as a Designated State Health Program under the state’s 1115 waiver, paid for projects that support the providers associated with the AEs. Each AE develops projects to help build its capacity in specific areas, including some related to behavioral health, such as implementation of evidence-based behavioral health integration and consultation services.
Through this work, officials found that behavioral health providers, even more so than primary care providers, needed a better understanding of alternative payment methodologies (APMs) and how to manage their practices to thrive under these arrangements. Those that had not previously served Medicaid enrollees (e.g., independent behavioral health providers) had even greater technical assistance needs because they often also had to learn Medicaid policies and create new infrastructure. One state official noted the program would have benefited from a comprehensive assessment of providers’, including behavioral health providers, technical assistance needs well before program launch to identify and address critical gaps in provider understanding before they affected the program’s success.
Quality
One of the aims of accountable care programs is to hold providers accountable for the quality of care they deliver. Colorado and Rhode Island chose not only to hold their ACOs accountable by measuring the outcomes they produce on quality metrics, but also the process each ACO used to achieve quality. Rhode Island requires each AE to establish a quality committee to oversee the AE’s quality assurance and improvement program. This state requires that the committee membership include at least one licensed behavioral health clinician who is an AE participant.
Colorado’s requirements are based in Medicaid managed care requirements. Each RAE must conduct two performance improvement projects each year. One of these projects must address behavioral health, and RAEs may choose to dedicate both to improving integration of physical and behavioral health care. RAEs must also prepare quality plans that address behavioral health.
Lessons Learned and Conclusion
Officials from the three states advised those seeking to use ACOs to improve behavioral health services to seek and use stakeholder input, leverage infrastructure and relationships built during previous initiatives as well as the knowledge and experience of the providers currently serving Medicaid enrollees, and expect growing pains. In addition, an examination of these states’ experience finds three overarching takeaways.
States worked to strengthen the primary care system and integrate primary care and behavioral health before introducing accountability for behavioral health services. State officials in all three states used an iterative process to incorporate behavioral health services into their ACOs. Both Colorado and Minnesota waited to incorporate behavioral health until they had several years of experience operating their programs. Colorado officials stated that even when they were planning the first phase of their program, they knew that they ultimately wanted to include behavioral health. They did not do so at that time because they wanted to first focus on ensuring that the primary care aspects of their program were working well. They also knew that the shift to the new delivery system was going to require the reworking of a long-standing behavioral health services delivery structure and believed that making major simultaneous changes to both primary and behavioral health care would cause too much disruption. Rhode Island included behavioral health in its accountable care program from the beginning, but had a very strong, widespread patient centered medical home (PCMH) program in place prior to launching the accountable care program.
All three states had also previously worked to increase behavioral health integration. Rhode Island, for example, had funded an Integrated Behavioral Health Pilot (IBH) that supported primary care practices in incorporating co-located behavioral health clinicians into their operations. Minnesota had established a behavioral health home program to promote whole-person care. Colorado established learning collaboratives to help primary care and behavioral health providers develop the skills needed to support integration, such as creating a multidisciplinary team.
States adjusted program policies as their own and other stakeholders’ experience grew. Both Colorado and Rhode Island reported that they considered their programs to be iterative after launch. Rhode Island officials shared that, during the third year of the program, they began requiring MCOs to calculate shared savings in a specific way and allowed the AEs to earn up to 50 percent of the savings based on their performance. The Medicaid agency made this change due to feedback from both AE and MCOs about the difficulty of managing a growing number of contracts, each with potentially different financial arrangements. Increased standardization also eased the state’s oversight and monitoring. Rhode Island had anticipated that it would need to adjust its policies as its experience grew because the Medicaid agency was, as one official described, “Designing, building, and flying [the airplane] at the same time.”
A Colorado official similarly reported that, “Our program is iterative, and we continue to tweak and learn from it.” Recently, Colorado is encountering challenges related to COVID-19, including questions about how to integrate specialty providers and behavioral health.
States found that ACO leadership, like their associated providers, benefit from support. Officials recognized and planned for provider support, although some wished that they had offered more support. The states also knew that ACOs would need support in order to achieve success. They found that many ACO technical assistance needs were similar to those of providers. Some ACOs, like providers, needed a better understanding of the type of alternative payment models that could work for behavioral health providers. Rhode Island engaged a contractor to provide individual and group technical assistance to both MCOs and AEs — one focus of which was to support both as they entered into shared-risk contracts.
Colorado reported that some newer RAEs had moved back to fee-for-service reimbursement for behavioral health providers but were now working with CMHCs to develop more value-based payment arrangements. Also similar to providers, ACOs that had not previously served Medicaid enrollees had greater technical assistance needs. In Colorado, new RAEs were less familiar with Colorado Medicaid and its emphasis on community-based services. One official wished that the state had allowed sufficient time during implementation to support peer learning for new RAEs, perhaps through shadowing existing contractors, underscoring that education and collaboration were critical. Although Colorado found that new RAEs needed to improve their understanding of Medicaid policies, experienced RAEs needed to be “shaken up” to encourage continued engagement and innovation. Officials in this state worked to engage both newer and more experienced RAEs in peer learning. As one official stated, “When they [RAEs] first started, it was a competition. Now they meet and learn from each-other.”
Conclusion
In recent years, states have begun to use Medicaid accountable care programs to better integrate behavioral and physical health, improve identification and treatment of behavioral health conditions, and increase Medicaid enrollees’ access to behavioral health care. Examining the strategies and outcomes of three of these states offers others valuable information that they can apply to their own programs. All three states’ Medicaid agencies took different approaches to selecting and paying their ACOs, but all three based ACO payment in performance and established ACO performance standards — and considered behavioral health in both of these aspects of their programs. All interviewees reported that their programs were improving care but, to date, only Colorado has published a summary of ACO performance on the measures that factor into payment. This state has seen some positive results, including a modest increase by all RAEs in the percent of Medicaid enrollees receiving behavioral health services and follow-ups after a positive depression screening.
End Notes
[1] “Report to Congress on Medicaid and CHIP”, Medicaid and CHIP Payment and Access Commission, June, 2015.
[2] Roeber, C., McClellan, C., and Woodward, A. “Adults in Poor Physical Health Reporting Behavioral Health Conditions Have Higher Health Costs”, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, April 26, 2016.
https://www.samhsa.gov/data/sites/default/files/report_2107/ShortReport-2107.html
[3] Roberts, L.W., Louie, A.K., Guerrero, A.P.S. et al, “Premature Mortality Among People with Mental Illness: Advocacy in Academic Psychiatry”, Academic Psychiatry, June 5, 2017. Psychiatryhttps://link.springer.com/article/10.1007/s40596-017-0738-9
[4] Correll CU, Galling B, Pawar A, et al,“Comparison of Early Intervention Services vs Treatment as Usual for Early-Phase Psychosis: A Systematic Review, Meta-analysis, and Meta-regression, JAMA Psychiatry, June 2018. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2679768
[5] “National Projections of Supply and Demand for Behavioral Health Practitioners: 2013-2025”, Health Resources and Services Administration, November, 2016. https://bhw.hrsa.gov/sites/default/files/bhw/health-workforce-analysis/research/projections/behavioral-health2013-2025.pdf
[6] E. McNichol and M. Leachman. States Continue to Face Large Shortfalls Due to COVID-19 Effects. Center on Budget and Policy Priorities. July 2020. https://www.cbpp.org/research/state-budget-and-tax/states-continue-to-face-large-shortfalls-due-to-covid-19-effects
[7] N. Panchel et al., The Implications of COVID-19 for Mental Health and Substance Use. Kaiser Family Foundation. April 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and-substance-use/
[8] L Hamel, et al. KFF Health Tracking Poll – July 2020. https://www.kff.org/coronavirus-covid-19/report/kff-health-tracking-poll-july-2020/
[9] Colorado Department of Health Care Policy and Fib=nuancing. ACC Operational Dashboard. September 2020.https://www.colorado.gov/pacific/sites/default/files/ACC%20Phase%20II%20Operational%20Dashboard%20September%202020.xlsx
[10] Rhode Island EOHHS. Attachment K – Infrastructure Incentive Program: Requirements for Managed Care Organizations and Certified Accountable Entities. http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/PY3Attach_K_Incentive_Program_Requirements_PY3_Final%20Updated%205.28.20%20for%20Web.pdf
[11] Colorado Department of Health Care Policy and Financing. Behavioral Health Incentive Program https://www.colorado.gov/pacific/sites/default/files/Accountable%20Care%20Collaborative%20Program%20Improvement%20Advisory%20Committee%20BHIP%20Preliminary%20Data%20Handout%20March%202020.pdf
Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank the state officials from Colorado, Minnesota, and Rhode Island who contributed to this brief as well as Health Resources and Services Administration Project Officer Carolyn Robbins and her colleagues for their feedback and guidance. The author also wishes to thank Trish Riley, Kitty Purington, Jodi Manz, and Kristina Long of NASHP for their contributions to the paper. This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under co-operative agreement number UD3OA22891, National Organizations of State and Local Officials. The information, content, and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
National Care Coordination Standards for Children and Youth with Special Health Care Needs
/in Policy Reports Care Coordination, Children/Youth with Special Health Care Needs, Children/Youth with Special Health Care Needs, CHIP, Chronic and Complex Populations, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration /by NASHP StaffThe National Care Coordination Standards for Children and Youth with Special Health Care Needs (CYSHCN) outline the core, system-level components of high-quality care coordination for CYSHCN. These standards are designed to help state officials and other stakeholders develop and strengthen high-quality care coordination for children with the goal of identifying and assessing the need for care coordination, engaging families in the care coordination process, building a strong and supportive care coordination workforce, and developing team-based communication processes to better serve children and families. Read an introductory blog about the report and download the report.
Introduction to National Care Coordination Standards for CYSHCN
About the National Care Coordination Standards for CYSCHN
Care coordination is a core component of federal and state efforts to improve health outcomes, reduce caregiver and patient burden, and decrease health care costs for children and adults with chronic and complex conditions. Historically, policymakers and health services researchers have focused on care coordination for adult populations rather than on care coordination for children. That trend has shifted in recent years as states place priority on integrated care for children and youth with special health care needs (CYSHCN). The care coordination needs of CYSHCN deserve special attention as they may differ from those of adults due to additional service sector involvement, provider specialties required, and changes to childrens’ health care conditions as they grow and mature.
In 2014 the National Standards for Systems of Care for Children and Youth with Special Health Care Needs (CYSHCN) were developed and updated in 2017, by the Association of Maternal and Child Health Programs and the National Academy for State Health Policy (NASHP), with support from the Lucile Packard Foundation for Children’s Health (LPFCH). These standards describe the recommended core elements of a system of care for CYSHCN. Key elements of care coordination are included in these national standards. However, state health officials and other stakeholders who work with CYSHCN and their families expressed a need for an in-depth set of care coordination standards that could serve as a guide for the establishment of robust, high-quality care coordination programs for CYSHCN and their families.
Children and youth with special health care needs are commonly defined as children who “have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.”[1] Increased attention has focused on a subset of CYSHCN that have been termed children with medical complexity (CMC).[2] This population of children is typically defined as having medical fragility, substantial functional limitations, increased need for health care services and increased health care costs.[3] Nearly one in five (18 percent) of all children in the United States have special health care needs, while CMC account for less than 1 percent of all children in the United States.[4], [5]
Care Coordination Standards Development Process
NASHP conducted a comprehensive literature review on care coordination for children and adults to provide an evidence base for the development of the National Care Coordination Standards for CYSHCN. The literature review examined and compiled evidence from studies of care coordination models (both pediatric and adult), examples of care coordination initiatives in states and health systems, and model frameworks, key elements, and definitions of care coordination. NASHP identified over 80 pieces of care coordination literature through internet and database searches, citations in journal articles, and information from subject-matter experts. NASHP’s literature review found that many studies have investigated the impact of care coordination on CYSHCN for a broad range of outcomes. Interpretation of the research is confounded by variability in the populations studied and heterogeneity in the different types of models used.[6] There are, however, essential characteristics of care coordination that were present across most evaluated care coordination programs that serve children. These elements include an identified care coordinator,[7] shared care plan,[8] child and family needs assessment[9] and goal setting,[10] provision of resources and education, and family support and advocacy.[11], [12]
Similar elements can be found in adult care coordination programs and include a comprehensive needs assessment, individualized care plans, connection to services and supports, and regular monitoring and communication.[13]
The Care Coordination Standards define care coordination as patient- and family-centered, assessment-driven, team-based activities designed to meet the needs of children and youth.
They address interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes, and efficient delivery of health-related services and resources within and across systems. |
Furthermore, the literature review identified more than a dozen definitions of care coordination. NASHP identified and synthesized key elements of multiple existing definitions of care coordination to develop a working definition for the purposes of the project. For the purpose of the National Care Coordination Standards for CYSHCN, care coordination is defined as: “patient- and family-centered, assessment-driven, team-based activities designed to meet the needs of children and youth. Care coordination addresses interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes, and efficient delivery of health-related services and resources within and across systems.”[14],[15],[16]
To further inform the development of the Care Coordination Standards, NASHP conducted more than a dozen key informant interviews with representatives from state Medicaid and Children’s Health Insurance Program (CHIP) programs, public health agencies, health plans, families of CYSHCN, health services researchers, adult care coordination programs, federal agencies (e.g., the Centers for Medicare & Medicaid Services (CMS) and the Health Resources and Services Administration (HRSA)), and others. Interviews were designed to seek early input from stakeholders to guide the project, gain insights on innovative and promising health care delivery models, identify policy considerations for development of the standards, and pinpoint priority areas for standards to address. A list of key informants is listed in Appendix B.
NASHP also convened a national work group of over 30 members representing state and federal agencies, child and family advocates, health plans and health insurers, and health care providers with expertise in CYSHCN who provided guidance and feedback throughout the project. The national work group was convened over an 18-month period, through two virtual and one in-person meeting in the fall of 2019 to guide and reach consensus on essential elements of care coordination, the specific domains of the standards, and priority areas for additional development. Themes from the key informant interviews and work group discussions are described in the next section.
Major Themes from Key Informants on the Focus of National Care Coordination Standards
Major themes from the key informant interviews and work group meetings are described below. These themes are reflected in the language of individual standards.
- An age-agnostic approach with a focus on the unique needs of CYSHCN: Care coordination programs should include a common set of elements, activities, and tools that can be applied to both pediatric and adult populations. However, specific models and strategies for care coordination for different populations can vary. Care coordination for the pediatric population should consider their unique needs and reflect the types of providers, community-based programs and supports, and delivery systems (e.g., education, early care and education, and social services) that serve children and youth.
- Family-centeredness: Building a trusting relationship with the family is a critical, and an oftentimes under-emphasized, element of care coordination programs and the responsibility of a care coordinator. The standards should reflect families as central to the care team. Care teams should operate in accordance with family beliefs, values, strengths, and aspirations. Family needs and preferences should guide all decisionmaking, including decisions about modes of communication among care team members.
- Relational care coordination: Care coordination should not be limited to “checking the box” when specified benchmarks are met. Rather, it should be a relational process. Care coordinators should aim to build trust and longitudinal relationships that enable effective engagement with CYSHCN and families to achieve shared goals. Families have the ultimate responsibility for coordinating their child’s services – often at considerable financial, physical, and psychological cost – and families have different preferences for how much assistance they would like in coordinating their child’s care. At the same time, care coordination programs should be structured so that care coordinators are not overburdened and can consistently follow through on tasks they are responsible for, to build trust with families and ensure that the needs of families are met including during times of crisis. Finally, families should be involved in advising and guiding the development and implementation of care coordination programs.
- High-quality, effective care coordination: Many CYSHCN are assigned numerous care coordinators, both within and outside of the health care system. Communication between care coordinators is often lacking. Siloed care coordination services can lead to duplication of services, weaken accountability systems, and burden families with the task of coordinating the coordinators. To avoid these outcomes, it is important to establish clear roles for care coordinators and to design effective, efficient systems for information-sharing.
- Health equity: Care coordination should be based on the premise of health equity, which is the concept that all children and families should have an equal opportunity to attain their full health potential, and no barriers should prevent children and their families from achieving this potential. The goal of advancing health equity should be foundational to all care coordination standards and guides care coordination activities. Care coordination systems should aim to reduce access barriers and increase the range of services that are available through care coordination to meet the diversity of families’ needs.
- Scope of care coordination: Care coordination is not limited to the management of health care services alone. Care coordinators should address the full range of social, behavioral, environmental, and health care needs of CYSHCN and their families. The role of a care coordinator should include connecting families to community resources to address health-related social needs.
- A dynamic process: Care coordination should be a dynamic process that adapts to meet the changing needs, circumstances, and preferences of the child and family. Core elements of the process, including the assessment and shared plan of care, should be updated regularly.
- Workforce and training: Care coordination workforce capacity and training is extremely important and should be considered in development of the Care Coordination Standards. The standards should not be overly prescriptive or limit care coordination to specific professional qualifications. Care coordinators should have the training and experience best aligned to meet the needs of CYSHCN. Lived experience of having or caring for a child with special health care needs should be an important consideration in hiring. Care coordinator training should address a broad range of issues beyond the realm of health care, such as cultural and linguistic competency and implicit bias.
- Quality measurement: To create systems of accountability for care coordination, appropriate outcome measures need to be identified or developed. These measures should focus on integration of services across systems, quality of life, reduction in duplicative and/or preventive health care utilization, as well as care coordination processes. Current emphasis on reduced utilization as an outcome of care coordination, especially prominent in the adult literature, is insufficient for pediatric care coordination. Instead, measures that capture the extent to which patients’ and families’ goals and needs are met and burdens reduced should be considered. Consequently, the impact of care coordination on CYSHCN may be measured best through family surveys and quality-of-life measures. Because care coordination should bridge between the health care system and other community-based services and systems (e.g., education, child welfare), the impact on those other services should be included in quality measurement.
- Insurance coverage and care coordinator payment: Payment systems should be adequate to support care coordination. Insurance coverage of care coordination should be available so that services are accessible, affordable and comprehensive. Payment or reimbursement for care coordination – and the compensation provided to care coordinators – should reflect the qualifications and workload of care coordinators, as well as the intensity of services they provide.
Guiding Principles for Development of the National Care Coordination Standards for CYSHCNThe following principles guided development of the National Care Coordination Standards for CYSHCN. These principles were informed by the work group and previous work in developing the National Standards for Systems of Care for CYSHCN.
|
Foundational Standards for Care Coordination
The National Care Coordination Standards for CYSHCN are guided by the following foundational standards. These seven standards are the foundation for all standards in each domain, and are critical to ensure comprehensive, high-quality care coordination for CYSHCN.
- Care coordination for CYSHCN is based on the premise of health equity, that all children and families should have an equal opportunity to attain their full health potential, and no barriers should exist to prevent children and their families from achieving this potential.
- Care coordination addresses the full range of social, behavioral, environmental, and health care needs of CYSHCN.
- Families are co-creators of care coordination processes and are active, core partners in decision making as members of the care team. CYSHCN, families, and care coordinators work together to build trusting relationships.
- Care coordination is evidence based where possible, and evidence informed and/or based on promising practices where evidence-based approaches do not exist.
- Care coordination is implemented and delivered in a culturally competent, linguistically appropriate, and accessible manner to best serve CYSHCN and their families.
- Insurance coverage of care coordination for CYSHCN allows for it to be accessible, affordable, and comprehensive.
- Performance of care coordination activities is assessed with outcome measures that evaluate areas including:
a. process of care coordination (e.g., number of families with a shared plan of care);
b. Family experience with integration of care across medical, behavioral, social and other sectors and systems;
c. Quality of life for CYSHCN and families; and
d. Reduction in duplicative and/or preventable health care utilization.
Domain 1: Screening, Identification, and Assessment
Screening, identification, and assessment of a child’s needs provides the foundation for effective, high-quality care coordination. Assessment is a continuous process that reflects ongoing conversations with CYSHCN and families about their needs, preferences, and priorities.
- A systematic, timely, and clearly documented screening process is in place to identify all children and families who are in need of care coordination.[17],[18]
- The process of screening a child to identify need for care coordination uses information and data from multiple sources, including providers, medical records, claims, hospital admission, discharge, and transfer (ADT) records, families and youth, education records, and records from other child-serving systems.
- The screening process for identifying a child’s care coordination needs considers multiple factors, including: [19],[20]
- Child and family strengths and resiliency;
- Complexity of the child’s health status, based on physical and behavioral health conditions, functional limitations (e.g., need for assistance with activities of daily living (ADLs)), and technology dependence;
- Health and social inequities that may create barriers to accessing and receiving needed care, services, or supports;
- Whether the child has had multiple preventable and/or planned hospital admissions and/or emergency department (ED) visits, receives treatment from multiple health care providers, or has unmet needs for evidence-based primary, preventive, and specialty care services;
- Social and environmental factors affecting health, such as housing instability, food insecurity, income, access to transportation, systemic racism and identity-based bias, and family risk factors, such as trauma and addiction; and
- Family beliefs, preferences, expressed needs, and goals for care coordination, based on past experiences and current priorities.
- If identified through screening as needing additional assessment for care coordination services, children and families have the option of engaging in a care coordination assessment and ultimately, whether to participate in or opt out of receiving care coordination services.
- Care coordination assessments should be the result of a collaborative conversation with families to identify needs and strengths.
- A care coordination assessment should be conducted in addition to, or in alignment with, other initial assessments upon enrollment in a health plan or other service delivery system.[21],[22]
- The care coordination assessment incorporates key information from the child’s physical and behavioral health status and history, as well as information about:[23],[24],[25],[26],[27],[28],[29]
- Insurance status;
- Eligibility for and involvement in public programs such as Medicaid, the Children’s Health Insurance Program (CHIP), Supplemental Security Income (SSI), the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), public housing assistance, the Title V CYSHCN program, early childhood education programs (e.g., Head Start), and other community services;
- Whether the child is involved in the justice system;
- Involvement in the child welfare system;
- Education needs;
- Language needs and preferences;
- Health literacy and health education needs;
- Social determinants of health;
- Preferred method of communication (e.g., phone, e-mail, in person);
- Demographics (including race and ethnicity);
- Availability of support systems, including a family support network;
- Unmet needs for services and support;
- The family’s self-management skills and capacity to navigate care systems;
- Health status of the caregiver and sibling(s), if applicable;
- Guardianship; and
- Foster care involvement.
- Action items documented in the care coordination assessment include child and family goal-setting that is based on family needs, priorities, and next steps, and whether the family consents to move forward with receiving care coordination services and supports.[30]
- The care coordination assessment includes documentation of connection to services both in the community and within the health care system to address identified needs.
- Care coordination assessment results are documented in a centralized electronic health record and shared with the family as soon as possible. With family consent and pursuant to all applicable laws and regulations, these results are shared with all members of the care team in a timely manner. [31],[32]
- The information collected during the care coordination assessment process can help identify the child’s risk for experiencing adverse outcomes. This risk is a factor in decision-making about the intensity of care coordination services.
- Care coordination reassessments are conducted at least every six months, or as determined by the family in collaboration with the care coordinator and/or provider. They are conducted regardless of whether the initial assessment resulted in the provision of care coordination services, as some assessments may not lead to the delivery of these services because a family may not need or choose to receive them. Reassessments also occur when there are significant changes in the child’s health and functional status, life circumstances, and/or social service needs.[33],[34],[35]
- The reassessment process includes a re-review of the child and family’s need for care coordination services.[xx] Reassessment documentation should include a mechanism to track whether and when the child receives recommended services.[36],[37]
Domain 2: Shared Plan of Care
The shared plan of care provides a roadmap and an accountability system for integrating care based on family needs and priorities identified in the assessment and is used in coordinating a child’s care.
- The shared plan of care is a dynamic document that addresses the clinical, functional, and social service needs identified in the assessment. The shared plan of care considers and builds on the child’s and family’s strengths, and it describes delivery and coordination of all needed services.
- The process for developing a shared plan of care:
a. Engages the family as an active and equal partner;[39],[40],[41]
b. Reflects the family’s unique knowledge, lived experiences, values, and beliefs;[42] and
c. Is both strength-based and trauma-informed. - The shared plan of care includes the child’s:[43]
a. Health summary (e.g., medical and behavioral health history, family preferences and strengths, treating providers, medications, immunizations), as well as personal, educational, behavioral, and social circumstances.
b. Long- and short-term clinical, functional (e.g., need for assistance with activities of daily living (ADLs)), developmental, and social (e.g., ability to interact with peers), goals – which are specific, achievable, and time-specific – as well as aspirational (e.g., long-term hopes). Aspirational goals include those that bring joy to the child and family (e.g., a special vacation).
c. Upcoming medical and social service transitions, as well as strategies to support continuity of care during times of transition.
d. Emergency plan, to be accessed by emergency medical technicians (EMTs) and emergency department (ED) providers as needed. The emergency plan includes a list of medications, needed accommodations (e.g., local anesthesia for intravenous access), allergies, a list of providers most involved in the child’s care, and their contact information.[44]
e. Disaster plan, which provides guidance for responding to situations such as loss of power, natural disaster, act of terrorism, and public health emergencies. - The shared plan of care goals specify measurable steps and benchmarks, as well as assigned time frames and persons responsible for completion of the plan.
- The shared plan of care identifies all members of the care team, including the care coordinator.
- The shared plan of care clearly delineates all care team member roles, responsibilities, and accountability, as agreed upon by the care team.[45],[46],[47]
- The shared plan of care indicates family and provider preferences for communication (e.g., phone, email, text) and includes information for families on how best to contact other members of the care team during work hours and after hours for routine and emergent matters.
- The shared plan of care references policies and procedures that the care coordinator will use to coordinate with any other care coordinators serving the child, to avoid communication gaps and duplication of services.
- The shared plan of care is reviewed and updated at least every six months or more frequently as needed, depending on the intensity of care coordination and/or in response to a triggering event (e.g., a medical emergency or significant change in health status). Care coordinators and members of the care team track progress toward goals and make updates to the shared plan of care to align with changes in the child’s functional, clinical, self-management, education, and social service needs.[48]
- The shared plan of care is accessible within a centralized electronic health record (EHR) to all members of the care team, including the family.[49] When access to the EHR is not feasible for a care team member, the care team will find alternate means for access to the most updated version of the plan at all times, such as securely emailing an electronic copy of the plan to the member.
- With the family’s consent and pursuant to applicable laws and regulations, the shared plan of care is shared with other providers and child-serving systems (e.g., education, child welfare, juvenile justice) to facilitate optimal coordination and integration of services for the child and family.
Domain 3: Team-Based Communication
Communication between members of the care team is timely, efficient, respectful, and culturally sensitive.
- Care teams are multidisciplinary and function within the context of a medical home that includes, but is not limited to, the family, primary care provider, medical and behavioral health specialists, care coordinator, and professionals from rehabilitation, social services, and education systems. Care coordinators are key members of the care team and lead care coordination efforts.
- The family is the center of the care team and informs all decision-making. The care team operates in accordance with the family’s values, beliefs, strengths, and aspirations.
- The care team has a clearly identified single point of contact for communication with the family, likely the care coordinator, who proactively addresses any barriers to communication as they arise.[50]
- The family’s language, cultural, technological, and communication preferences are documented and shared with all other members of the care team. Care team communication with family members is in accordance with the family’s preferences.
- All written materials provided to CYSHCN and their families are culturally appropriate and provided in their primary language whenever possible. Written materials should be formatted and delivered in a manner that is appropriate for children and their parents or caregivers who have limited English proficiency, lower levels of literacy, or sensory impairments.
- When communicating with the family, the care team, including the care coordinator, makes optimal use of electronic notification systems, smartphone technology, electronic care management systems (i.e., IT systems to track care coordination), and other electronic tools in accordance with applicable laws and regulations, as well as family preferences and abilities.
- Care coordinators aim to build trust and longstanding relationships with the child and family. These relationships should promote shared goals, knowledge, and mutual respect.
- Families have the option of changing care coordinators at any time. Care teams have established procedures to communicate changes in care team members and roles, and to transfer responsibilities from one care coordinator to another as needed.
- All members of the care team can support families in accessing care coordination services.
- Care team members remain in regular communication with each other and with any other providers serving the child using electronic tools, to the extent possible, to address challenges, and discuss solutions in a timely and efficient manner.
- The care team receives regular reports from an electronic care management system and/or the care coordinator. These reports include but are not limited to:
a. Changes in the child’s clinical or functional status;
b. Changes in family status;
c. Hospital admissions and discharges;
d. Emergency department visits;
e. Transfers to subacute care facilities (e.g., rehabilitation centers);
f. Completed reassessments;
g. Updates to the shared plan of care;
h. Planned and unplanned transitions in care; and
i. Changes in insurance status. - Care coordinators have policies and procedures in place to identify any other care coordinators who are serving the child, and to facilitate communication and coordination between them.
- The care coordinator communicates and has referral arrangements with community-based organizations and agencies to address the child’s medical, financial, educational, and social needs.
Domain 4: Child and Family Empowerment and Skills Development
Care coordination includes education, coaching, and training for CYSHCN, families, and care teams. These activities empower children and families and advance their well-being, while at the same time enabling other members of the care team to gain the understanding and insights needed to serve families effectively.
- Based on findings from the assessment and reassessments, the care coordinator and other members of the care team provide training and/or coaching to help children and families to: [51],[52]
a. Leverage their strengths;
b. Increase understanding of the child’s condition(s);
c. Build self-management and self-efficacy skills (e.g., medical and durable medical equipment management, navigation of the health care system, optimal use of electronic tools to facilitate coordination, transition from pediatric to adult systems, and communication with providers); and
d. Develop the knowledge and skills needed to achieve their identified goals. - The care coordinator and other members of the care team connect the child and family to peer supports (e.g., parent and youth mentors, support groups, family advocacy groups, internet-based patient communities, and condition-specific organizations) as appropriate. Peer supports leverage the value of lived experience in obtaining access to needed services, provide guidance for navigating systems of care, and help the child and family build confidence and competence in articulating goals and expectations.[53]
- Individuals with lived experience, including family members serving as officially designated care coordinators, either for their children or for other children, receive appropriate compensation for providing care coordination services.[54]
Domain 5: Care Coordination Workforce
The care coordination workforce is well trained and prepared to serve CYSHCN and their families. All care team members have opportunities to gain the knowledge and understanding needed to perform their roles effectively.
- A child’s care coordinator has the credentials and experience that is best aligned to meet the needs of the child. Licensed as well as nonlicensed providers, including but not limited to nurses, social workers, patient advocates, community health workers, and family members may serve as care coordinators.[55]
- The care coordination workforce is culturally, linguistically, racially, and ethnically diverse.
- Care coordinators have the competencies needed for successful navigation across health, behavioral health, social service, and other child-serving systems. An individual’s lived experience or practical knowledge and understanding of navigating the health system is an important consideration in care coordination hiring.
- Care coordinators engage in training to achieve the knowledge, skills, and abilities needed for effective care coordination. Family caregivers have the opportunity to obtain care coordinator training and credentialing. Training is an ongoing process with continuing education opportunities. Training topics may include but are not limited to:[56],[57]
- Learning from and building partnerships with families;
- Motivational interviewing;
- Identification of family strengths, priorities, and goal setting;
- Shared plan of care development;
- Cultural and linguistic competency;
- Implicit bias;
- Health insurance policies and procedures;
- Confidentiality;
- Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA) compliance training;
- Health literacy;
- Community-based resources;
- Transition and referral processes; and
- Education systems for CYSHCN.
- Care coordination caseload ratios account for factors affecting capacity, such as variations in case complexity, travel times for in-person visits, and intensity of care coordination services.[58],[59]
- Policies, procedures, and mechanisms are in place, including child and family feedback, to review care coordinator and care team activities on a regular basis to assess the quality of care coordination and related outcomes.[60],[61]
- Payment or reimbursement for care coordination reflects the qualifications, workload, and intensity of services provided by care coordinators.[62]
Domain 6: Care Transitions
Care transitions refer to the transfer of care between and within medical, behavioral health, social service, education, and justice systems. Particular emphasis is placed on preparing youth for transitions from pediatric to adult care and promoting independence in the transition to adulthood. Advance preparation and careful integration of services following transitions are essential to a successful transition process.
- Care coordination policies and procedures are developed to facilitate effective transitions between and among providers, care settings, health insurance entities (e.g., private insurers or Medicaid), education, justice, behavioral health, and social service systems, and other entities. These policies and procedures should:[63],[64],[65]
- Be driven by youth and families, based on their goals, needs, and preferences;
- Clearly identify roles and responsibilities of the family, care team members, providers, and other entities involved in transitions; and
- Identify and track engagement with transition support services.
- Care coordinators and/or other members of the care team work proactively with families to formulate a plan that identifies upcoming transitions and determines transition-related needs, and to conduct a readiness assessment using a standardized tool to inform transition procedures.[66],[67],[68]
- Updated records from the health care, social service, education, behavioral health, and justice systems, including the most recently updated shared plan of care, are made available to youth and families to support successful transitions and enable continuity of services.[69],[70]
- The child’s care team works to identify appropriate providers for youth transitioning from pediatric to adult health care systems, facilitate warm hand-offs between providers,[71] and advance CYSHCN independence, self-efficacy, and self-advocacy in the transition to adulthood.
National Care Coordination Standards for CYSHCN Infographic
Appendix A: Glossary of Terms
- Assessment: a health assessment that identifies the specific needs, beliefs and goals of the family and child and how they can be best addressed by the health care system.
- Care Coordination: patient and family-centered, assessment-driven, team-based activities designed to meet the needs of children and youth that address interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes and efficient delivery of health-related services and resources both within and across systems.[72], [73], [74]
- Care Coordinator: an identified individual who can assist patients, families and caregivers with referrals to specialists and other care providers, communication between the child’s primary care physician, service providers and subspecialty physicians, support for family concerns, and problem solving to promote the patients’ well-being.[75]
- Care Teams: a multidisciplinary team, including care coordinators, primary, specialty, and social service providers, functioning as part of an expanded medical home in which the family is an equal team member and partner.
- Centralized Electronic Health Record: a digital version of a patient’s paper chart that instantly allows authorized users to securely access real-time, patient-centered records information.[76]
- Children and Youth with Special Health Care Needs (CYSHCN): Children who have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally.[77]
- Health Literacy: the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.[78]
- Persons with lived experience: individuals who have first-hand experience of the medical and/or behavioral health condition(s) under consideration. This may be someone who has been diagnosed with the condition themselves or a caregiver of someone diagnosed with the condition.[79]
- Medical Home: Also known as Patient or Family-Centered Medical Home, a Medical Home is an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, behavioral health specialists, care coordinators, families, and professionals from rehabilitation, social services, and education systems.[80]
- Outcome Measures: measures that reflect the impact of a health care service or intervention on the health status of patients.[81]
- Shared Plan of Care: a concise yet comprehensive, integrated, and user-friendly compilation of child and family specific information and goals that guides care and facilitates its coordination among the family and their lead clinical team in concert with the appropriate “constellation” of subspecialists and community resource providers.[82]
- Trauma-informed Care: an approach in the human service field that assumes that an individual is more likely than not to have a history of trauma, recognizes the presence of trauma symptoms, and acknowledges the role trauma may play in an individual’s life.[83]
Appendix B: Key Informants
- Family Leaders
- Cara Coleman, Program Manager, Family Voices
- Teresa Jurado, Parent Mentor, Stanford Children’s Hospital
- Rylin Rodgers, Director of Public Policy, Association of University Centers on Disabilities
- Nora Wells, Executive Director, Family Voices
- Family Voices State Affiliate Organization Representatives
- Children’s Hospitals
- Tracy Huentelman, Senior Project Specialist, Cincinnati Children’s Hospital Medical Center
- John Morehous, Medical Director, Fairfield Primary Care, Cincinnati Children’s Hospital Medical Center
- Health Plans
- Jennifer Kyle, Vice President Product Strategy, Special Needs Initiative, UnitedHealthcare
- Centers for Medicare & Medicaid Services (CMS)
- Renee Fox, Division of Quality and Health Outcomes, Center for Medicaid and CHIP Services
- Melissa Harris, Disabled and Elderly Health Programs Group, Center for Medicaid and CHIP Services
- Susan Ruiz, Oral Health and EPSDT lead, CMS San Francisco Regional Office, Division of Medicaid & Children’s Health Operations
- Ellen Marie Whelan, Chief Population Health Officer, Center for Medicaid and CHIP Services
- Health Resources and Services Administration (HRSA)
- Treeby Brown, Chief, Integrated Services Branch, Maternal and Child Health Bureau, HRSA
- Marie Mann, Senior Medical Advisor, Maternal and Child Health Bureau, HRSA
- Leticia Manning, Public Health Analyst, Maternal and Child Health Bureau, HRSA
- Providers/Provider Groups
- Rich Antonelli, Medical Director, Integrated Care, Boston Children’s Hospital
- Dennis Kuo, Chief, Division of General Pediatrics, University of Buffalo
- Kathleen Noonan, Camden Coalition of Healthcare Providers
- State Medicaid Programs
- Sandra Brown, Integrated Care Management Manager, Virginia Department of Medical Assistance Services (DMAS)
- Emily Creveling, Maternal and Child Health Manager, Virginia DMAS
- Katie Hill, Integrated Care Senior Advisor, Virginia DMAS
- Estelle Kendall, Nurse Case Manager, Virginia DMAS
- State Title V CYSHCN Programs
- Jeff Brosco, Florida Title V CYSHCN Director
National Care Coordination Standards for CYSHCN Work Group Members
Richard Antonelli | Medical Director, Integrated Care Boston Children’s Hospital |
Marlene Asmussen | Director, Population Care Management Oklahoma Health Care Authority |
Kayzy Bigler | Children & Families Unit Director, Bureau of Family Health Kansas Department of Health and Environment |
Jeffrey Brosco | Professor of Clinical Pediatrics University of Miami Title V CYSHCN Director, Florida Department of Health |
Sandra Brown | Integrated Care Management Manager Virginia Department of Medical Assistance Services |
Treeby Brown | Chief, Integrated Services Branch Division of Services for Children with Special Health Needs Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) |
Allegra Burrell | Ambulatory Case Manager, Goldberg Center for Pediatrics Children’s National Medical Center |
Cara Coleman | Program Manager Family Voices |
Meg Comeau | Senior Project Director The Catalyst Center at Boston University |
Mary Daymont | Vice President of Revenue Cycle and Care Management Children’s National Health System |
Renee Fox | Medical/Health Policy Advisor Division of Quality and Health Outcomes Center for Medicaid and CHIP Services/The Children and Adults Health Programs Group Centers for Medicare & Medicaid Services |
Deborah Garneau
|
Director, Health Equity Institute Maternal and Child Health/Special Needs Director Rhode Island Department of Health |
Holly Henry | Program Director Lucile Packard Foundation for Children’s Health |
Dennis Kuo | Associate Professor and Division Chief, General Pediatrics Department of Pediatrics University of Buffalo, Jacobs School of Medicine and Biomedical Sciences |
Jennifer Kyle | Vice President Product Strategy, Special Needs Initiative UnitedHealthcare |
Carolyn Langer | Senior Vice President and Chief Medical Officer Fallon Health |
Eric Levey | Chief Medical Officer Health Services for Children with Special Needs, Inc. The HSC Health Care System, Washington, DC |
Marie Mann | Senior Medical Advisor/Acting Deputy Director Division of Services for Children with Special Health Needs Health Resources and Services Administration, Maternal and Child Health Bureau |
Jeanne McAllister | Adjunct Associate Research Professor of Pediatrics Indiana University School of Medicine |
Margaret McManus | Co-director, Got Transition President, The National Alliance to Advance Adolescent Health |
John Morehous | Medical Director, Community Health Services Network Cincinnati Children’s Hospital Medical Center Assistant Professor of Pediatrics University of Cincinnati College of Medicine |
Kathleen Noonan | Chief Executive Officer Camden Coalition of Healthcare Providers |
Jennifer Oppenheim | Senior Advisor on Early Childhood Lead, Project LAUNCH Substance Abuse and Mental Health Services Administration |
Rylin Rodgers | Director of Public Policy Association of University Centers on Disabilities |
Heather Smith | Director, Title V CSHCN and System of Supports Section Bureau of Family Health Kansas Department of Health and Environment |
Colleen Sonosky | Associate Director, Children’s Health Services Department of Health Care Finance, Washington, DC |
Kate Taft | Associate Director, Child & Adolescent Health Association of Maternal and Child Health Programs |
Wendy Tiegreen | Director, Office of Medicaid Coordination & Health System Innovation Georgia Department of Behavioral Health and Developmental Disabilities |
Renee Turchi | Chair of Pediatrics, St. Christopher’s Hospital for Children Professor, Drexel University College of Medicine and School of Public Health |
Debra Waldron | Senior Vice President Healthy and Resilient Children, Youth, and Families American Academy of Pediatrics |
Notes
[1] McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics. 1998;102(1 Pt 1):137-140.
[2] Cohen E, Berry JG, Sanders L, Schor EL, Wise PH. Status Complexicus? The Emergence of Pediatric Complex Care. Pediatrics. 2018;141(Supplement 3):S202-S211.
[3] Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529-538.
[4] Child and Adolescent Health Measurement Initiative. 2017 National Survey of Children’s Health (NSCH) data query. Data Resource Center for Child and Adolescent Health supported by Cooperative Agreement U59MC27866 from the U.S. Department of Health and Human Services, Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA MCHB). Retrieved from https://www.childhealthdata.org/browse/survey/results?q=6546&r=1.
[5] Cohen E, Berry JG, Camacho X, Anderson G, Wodchis W, Guttmann A. Patterns and costs of health care use of children with medical complexity. Pediatrics. 2012;130(6):e1463-1470.
[6] J P. A Review of the Literature for Outcomes Associated with Aspects of Care Coordination and the Presence of a Care Coordinator for Children with Complex Needs. Center of Excellence on Quality of Care Measures for Children with Complex Needs. 2012.
[7] Peter S, Chaney G, Zappia T, Van Veldhuisen C, Pereira S, Santamaria N. Care coordination for children with complex care needs significantly reduces hospital utilization. J Spec Pediatr Nurs. 2011;16(4):305-312.
[8] McAllister JW, Presler E, Cooley WC. Practice-based care coordination: a medical home essential. Pediatrics. 2007;120(3):e723-733.
[9] Peter S et al., Care coordination for children with complex care needs.
[10] Farmer JE, Clark MJ, Drewel EH, Swenson TM, Ge B. Consultative care coordination through the medical home for CSHCN: a randomized controlled trial. Matern Child Health J. 2011;15(7):1110-1118.
[11] Peter S et al., Care coordination for children with complex care needs.
[12] Farmer JE, Clark MJ, Sherman A, Marien WE, Selva TJ. Comprehensive primary care for children with special health care needs in rural areas. Pediatrics. 2005;116(3):649-656.
[13] Stewart K, Bradley K et al. Care Coordination for Children with Special Health Care Needs in Medicaid: Lessons from Medicare. Am. Journal of Managed Care; 24(4); April 2018.
[14] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[15] Council on Children With Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5).
[16] “Care Coordination Measures Atlas Update”, Agency for Healthcare Research and Quality, June 2014, https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter2.html.
[17] Bachman S, Comeau M, Jankovosky K. The Care Coordination Conundrum and Children and Youth with Special Health Care Needs. Boston, MA: The Catalyst Center; 2015.
[18] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4. Care Management and Support, Competency A.
[19] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4. Standard CM-01.
[20] Silow-Carroll S, Rodin D, Pham A. Interagency, Cross-Sector Collaboration to Improve Care for Vulnerable Children: Lessons from Six State Initiatives. Albany, NY: Health Management Associates; 2018.
[21] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[22] Bachman S, Comeau M, Jankovosky K. The Care Coordination Conundrum and Children and Youth with Special Health Care Needs. Boston, MA: The Catalyst Center; 2015.
[23] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[24] Barth S et al., Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches. Health Management Associates: March 2019.
[25] Kuo D et al., Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?. Pediatrics: March 2018.
[26] Massachusetts Child Health Quality Coalition. Care Coordination Strengths and Needs Assessment: Recommendations for a Structured Tool. February 2015. http://www.masschildhealthquality.org/wp-content/uploads/2015/02/1.-CHQC-CC-Needs-Assessment-Tool-Recommendations-HIGH-LEVEL.pdf
[27] Care Coordination Measures Atlas Update. Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/index.html
[28] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4. Standard KM-02.
[29] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017. Standards CM-2 Element D, LTSS-1 Element F, LTSS-1 Element G.
[30] Stille C et al., Aligning Services with Needs: Characterizing the Pyramid of Complexity Tiering for Children with Chronic and Complex Conditions. 2018. Lucille Packard Foundation for Children’s Health.
[31] Stille C et al., Aligning Services with Needs: Characterizing the Pyramid of Complexity Tiering for Children with Chronic and Complex Conditions. 2018. Lucille Packard Foundation for Children’s Health.
[32] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4. Standard CM-02, Element C.
[33] Stille C et al., Aligning Services with Needs: Characterizing the Pyramid of Complexity Tiering for Children with Chronic and Complex Conditions. 2018. Lucille Packard Foundation for Children’s Health.
[34] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4. Standard CM-02, Element C.
[35] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Population Health Program Accreditation 2019. Standard PHP 4, Element A.
[36] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[37] Care Coordination Measures Atlas Update. Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD.
[38] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Population Health Program Accreditation 2019. Population Segmentation, element A.
[39] National Quality Forum (NQF), Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report, Washington, DC: NQF; 2010.
[40] McAllister, J. (2014 ). Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: A White Paper and Implementation Guide, Lucille Packard Foundation for Children’s Healthcare.
[41] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017
[42] McAllister, J. (2014 ). Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: A White Paper and Implementation Guide, Lucille Packard Foundation for Children’s Healthcare.
[43] Ibid.
[44] American Academy of Pediatrics. Council on Children with Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems. Pediatrics May 2014, 133 (5) e1451-e1460. https://pediatrics.aappublications.org/content/133/5/e1451.full
[45] National Quality Forum (NQF), Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination: A Consensus Report, Washington, DC: NQF; 2010.
[46] McAllister, J. (2014 ). Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: A White Paper and Implementation Guide, Lucille Packard Foundation for Children’s Healthcare.
[47] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017.
[48] Patience H. White, W. Carl Cooley. Transitions Clinical Report Authoring Group, American Academy of Pediatrics, American Academy of Family Physicians, and American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home Pediatrics November 2018, 142 (5) e20182587. https://pediatrics.aappublications.org/content/142/5/e20182587.
[49] Berry JG, Goldmann DA, Mandl KD, et al. Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study. BMC Health Serv Res. 2011;11:117
[50] Ziniel SI, Rosenberg HN, Bach AM, Singer SJ, Antonelli RC. Validation of a Parent-Reported Experience: Measure of Integrated Care. Pediatrics. 2016;138(6):e20160676
[51] AHRQ Care Coordination Measures Atlas, Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[52] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[53] “Joint Principles of the Patient-Centered Medical Home,” American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, and American Osteopathic Association, March 2007, https://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
[54] Antonelli, RC, Huth, Rosenberg, H, Bach, A, Eds. Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital. 2019. https://medicalhomeinfo.aap.org/tools-resources/Documents/PCCC%202nd%20Edition/Full%20Pediatric%20Care%20Coordination%20Curriculum.pdf
[55] Thorpe JH, Hayes K. Selected Provisions from Integrated Care RFPs and Contracts: Care Coordination. Integrated Care Resource Center. 2013. http://www.chcs.org/media/ICRC_Care_Coordination_FINAL_7_29_13.pdf
[56] Boston Children’s Hospital. Care coordination curriculum. 2013. Available at: www.childrenshospital.org/care-coordination-curriculum.
[57] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017.
[58] Thorpe JH, Hayes K. Selected Provisions from Integrated Care RFPs and Contracts: Care Coordination. Integrated Care Resource Center. 2013. http://www.chcs.org/media/ICRC_Care_Coordination_FINAL_7_29_13.pdf
[59] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017
[60] Ziniel SI, Rosenberg HN, Bach AM, Singer SJ, Antonelli RC. Validation of a Parent-Reported Experience: Measure of Integrated Care. Pediatrics. 2016;138(6):e20160676
[61] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Case Management Accreditation 2017
[62] Sara S. Bachman, Meg Comeau, and Katharyn M. Jankov, “The Care Coordination Conundrum and Children and Youth with Special Health Care Needs,” The Catalyst Center, November 2015, http://cahpp.org/wp-content/uploads/2016/03/Care-Coordination-Conundrum.pdf
[63] Got Transition, Center for Health Care Transition Improvement. Six Core Elements of Health Care Transition 2.0. Available at: http://www.gottransition.org/resourceGet.cfm?id=206.
[64] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4.
[65] American Academy of Pediatrics. American Academy of Family Physicians, and American College of Physicians. Transitions Clinical Report Authoring Group. Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics. 2011; 128-182.
[66] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009.
[67] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4.
[68] White, Patience H, and Carl Cooley. “White PH, Cooley WC; Transitions Clinical Report Authoring Group; American Academy of Pediatrics; American Academy of Family Physicians; American College of Physicians. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics. 2018;142(5):e20182587.” Pediatrics 143, no. 2 (2019). https://doi.org/10.1542/peds.2018-3610.
[69] Care Coordination Measures Atlas Update. Content last reviewed June 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic care/improve/coordination/atlas2014/index.html
[70] National Committee for Quality Assurance. Standards and Guidelines for NCQA’s Patient-Centered Medical Home (PCMH) 2017, Version 4.
[71] Agency for Healthcare Research and Quality. Implementation Quick Start Guide Warm Handoff: The Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-qsg-brochure.pdf
[72] Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York, NY: The Commonwealth Fund; 2009
[73] Council on Children With Disabilities and Medical Home Implementation Project Advisory Committee. Patient- and family-centered care coordination: a framework for integrating care for children and youth across multiple systems. Pediatrics. 2014;133(5).
[74] “Care Coordination Measures Atlas Update”, Agency for Healthcare Research and Quality, June 2014, https://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/atlas2014/chapter2.html.
[75] “Managing the Practice: Patient Care Coordinator.” American Academy of Pediatrics, n.d. https://www.aap.org/en-us/professional-resources/practice-transformation/managing-practice/Pages/Patient-Care-Coordinator.aspx.
[76] “What Is an Electronic Health Record (EHR)?” Health IT.gov, September 10, 2019. https://www.healthit.gov/faq/what-electronic-health-record-ehr.
[77] “Children with Special Health Care Needs.” HRSA Maternal and Child Health. Health Resources and Services Administration, August 2019. https://mchb.hrsa.gov/maternal-child-health-topics/children-and-youth-special-health-needs.
[78] The Patient Protection and Affordable Care Act of 2010, Title V. https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf
[79] Rittenbach, Katherine, Candice G. Horne, Terence O’Riordan, Allison Bichel, Nicholas Mitchell, Adriana M. Fernandez Parra, and Frank P. Macmaster. “Engaging People with Lived Experience in the Grant Review Process.” BMC Medical Ethics 20, no. 1 (December 16, 2019). https://doi.org/10.1186/s12910-019-0436-0.
[80] “What Is Medical Home?” Engaging Patients and Families. American Academy of Pediatrics, n.d. https://www.aap.org/en-us/professional-resources/practice-transformation/managing-patients/Pages/what-is-medical-home.aspx.
[81] “Types of Health Care Quality Measures.” Agency for Healthcare Research and Quality, July 2015. https://www.ahrq.gov/talkingquality/measures/types.html.
[82]McAllister, Jeanne W. “Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs: An Implementation Guide.” Lucile Packard Foundation for Children’s Health, May 2014. https://www.lpfch.org/sites/default/files/field/publications/achieving_a_shared_plan_of_care_implementation.pdf.
[83] “What Is Trauma-Informed Care?” The Institute on Trauma and Trauma-Informed Care (ITTIC). University of Buffalo Center for Social Research, n.d. http://socialwork.buffalo.edu/social-research/institutes-centers/institute-on-trauma-and-trauma-informed-care/what-is-trauma-informed-care.html.
Acknowledgements
The National Academy for State Health Policy (NASHP) extends its thanks and appreciation to the Lucile Packard Foundation for Children’s Health for its support of this work and in particular, program director Holly Henry, and Edward Schor, former senior vice president with the foundation. NASHP also sincerely thanks the many individuals at the national and state level who contributed their time, insights, and expertise to development of the standards. We acknowledge their critical input and guidance to this work. These experts include the members of the National Care Coordination Standards Work Group and the project’s key informants.
This work was led by NASHP Senior Program Director Karen VanLandeghem and authored by her, NASHP Project Director Kate Honsberger, project consultants David Bergman, Stanford Children’s Hospital, and Ellen Bayer; and current and former NASHP Research Analysts Eddy Fernandez, Anna (Tilly) Tanga, and Hannah Eichner.
About NASHP
The National Academy for State Health Policy is a nonpartisan forum of policymakers throughout state governments, learning, leading, and implementing innovative solutions to health policy challenges. To accomplish our mission NASHP:
- Convenes state leaders to solve problems and share solutions;
- Conducts policy analyses and research;
- Disseminates information on state policies and programs; and
- Provides technical assistance to states.
The responsibility for health care and health care policy does not reside within a single state agency or department. NASHP provides a unique forum for productive interchange across all lines of authority, including the executive and legislative branches.
About the Lucile Packard Foundation for Children’s Health
The Lucile Packard Foundation for Children’s Health works in alignment with the Lucile Packard Children’s Hospital Stanford and the child health programs of Stanford University. The mission of the foundation is to elevate the priority of children’s health and increase the quality and accessibility of children’s health care through leadership and direct investment. The vision of the Lucile Packard Foundation for Children’s Health is that all children in the communities it serves are able to reach their maximum health potential.
Sign Up for Our Weekly Newsletter
Sign Up for Our Weekly Newsletter
Washington, DC Office:
1233 20th St., N.W., Suite 303Washington, DC 20036
p: (202) 903-0101
f: (202) 903-2790
Contact Us
Phone: 202-903-0101