New Directions in Medicaid
Initiatives for People with Mental Illness
Dena Stoner, Senior Policy Advisor
Texas Department ...
The Most Dangerous Phrase in the
English Language
“We’ve Always
Done It This Way”
2
3
Innovation Cycle
Medicaid Opportunities
• Demonstrations - Money Follows the
Person Behavioral Health Pilot
• State Medicaid Plan Options –...
Why focus on Mental Illness?
• Mental illness has costly human and financial consequences
• Texans with severe mental illn...
Money Follows the Person
Behavioral Health Pilot
(MFP BH)
6
The Challenge
• National data indicated that large numbers of
nursing facility residents have a primary diagnosis
of menta...
Video: In the Nursing Home
8
The Opportunity
• 2008- Texas awarded MFP demonstration
grant, funded by the Centers for Medicare
and Medicaid Services
• ...
MFP BH Pilot Goals
• Transition adults with severe mental illness
and/or substance abuse disorders from
nursing facilities...
BH Pilot Scope
• Includes adults with mental health or substance
use conditions and functional limitations who
have reside...
BH Pilot Services
• Coordinated with other services provided
through Medicaid managed care
• Pre-Transition Services - up ...
Cognitive Challenges
• Apathy
– A person does not start necessary activities on
their own or does not complete all the ste...
Cognitive Adaptation Training
(CAT)
• Evidence-based psycho-social intervention
• Uses a motivational strengths perspectiv...
Organizing Activities
Sam’s Daily Checklist
MON TUE WED THU FRI SAT SUN
Charge
phone
Use
Deodorant
Put on
shoes
Put on
cle...
Adaptations
16
Organizing the Environment
171717
Apathy Disinhibition Mixed
Compensating, Not “Curing”
Executive
Function
Attention
Memory
Psychomotor
Speed
Performance
of ADL’s
Social
Function
Occu...
CAT Intervention Categories
• Hygiene
• Medication
Management
• Orientation
• Money Management
• Transportation
• Eating/N...
Substance Use Services
• Assessment
• Individual &
Group Counseling
• Tobacco Cessation
Counseling
• Peer Support
• 24-hou...
Participant Characteristics
• Average Age was 59 (range 26-89)
• 54% are female
• 29% Hispanic, 17% African American,
52% ...
Functional Measures
• The Quality of Life Scale (QLS) (21 items) was developed to
evaluate deficit symptoms and impaired f...
23
24
25
The Pilot Today
• Over 291 people have been served since 2008
• Approximately 70% of BHP participants served remain in the...
The Future
• Managed care organizations will provide Medicaid
rehabilitative and case management services for
people with ...
Video: A New Beginning
28
MFP-BH Return to NF Outcomes
• Medicaid data showing nursing facility stays were
obtained for 213 participants to determin...
Home and Community-based
Services – Adult Mental Health
30
The Challenge
• Some adults who have severe mental illness
experience extended inpatient commitments –
sometimes lasting f...
The Opportunity
• 1915(i) of SSA enables states to provide HCBS
under a Medicaid state plan amendment
• Can target a broad...
Moving Upstream:
Incentives for Prevention of
Chronic Disease
33
The Challenge
• The leading causes of death for people with severe mental
illness are chronic health conditions such as he...
The Opportunity
• Texas awarded a Medicaid Incentives for Prevention of
Chronic Disease (MIPCD) Federal Grant
• Texas MIPC...
36 36
WIN Interventions
• Person-centered wellness planning with professional
health navigators, who are trained in Motiva...
WIN Features
• Rapid cycle improvement process
• Partnership: Stakeholder Advisory Group, Medicaid
Office, Medicaid MCOs
•...
The Goal
• People with mental illness less likely to
become or remain institutionalized
• People with behavioral health co...
39
Contact Information
Dena Stoner, Senior Policy Advisor
Texas Department of State Health Services
dena.stoner@dshs.state.tx...
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New Directions in Medicaid - Initiatives for People with Mental Illness

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Dana Stoner, Senior Policy Advisor with Texas Department of State Health Services, shared three examples of "changing the system" at the June 3, 2014 workshop on Designing Healthcare in Texas. The presentation was part of a Medicaid 101 overview and started the two day event sponsored by One Voice Texas, Harris County Healthcare Alliance, and Kinder Institute.

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  • Process Model

    Set clear guidelines of performance expectations
    2. Use fidelity monitoring to understand the effectiveness of intervention and retention
    3. Identify gaps in progress and efficiency
    4. Work with all team members to identify ways to close the gap
    5. Test the new ideas on a small scale
  • UT-Austin clip 3:57-7:19
  • Dena
    “AA is not the only way” – customized to people that have been institutionalized (going to someone’s home), w/c basketball group, going out into the community and supporting people as they engaging the community
    We’ll see a video of Ron who went through the program and is now providing peer support
  • 1. Scale of 1 to 5
    1.5 Linear and curvilinear trends are present
    2. Blue bars represent the 95% confidence about how future scores would likely look if this program were expanded throughout Texas
    3. Non-overlap of Time 0 blue bar with other shows initial improvement has been maintained even if it fluctuates across time
    4. Greater width of error bars represents greater fluctuation across time in outcomes, especially post-intervention
    5. However, good news remains regarding improvement in functional outcomes
  • Linear and curvilinear trends are present
    1.5 Scale of 1 to 5
    2. Blue bars represent the 95% confidence about how future scores would likely look if this program were expanded throughout Texas
    3. Non-overlap of Time 0 blue bar with other shows initial improvement has been maintained even if it fluctuates across time
    4. Greater width of error bars represents greater fluctuation across time in outcomes, especially post-intervention
    5. However, good news remains regarding improvement in functional outcomes
  • 1. Linear and curvilinear trends are present
    2. Blue bars represent the 95% confidence about how future scores would likely look if this program were expanded throughout Texas
    3. Non-overlap of Time 0 blue bar with other shows initial improvement has been maintained even if it fluctuates across time
    4. Greater width of error bars represents greater fluctuation across time in outcomes, especially post-intervention
    5. However, good news remains regarding improvement in functional outcomes
  • Tom
     
    For people with health needs that land them in a nursing facility level of care, the cost of living in the community under MFP is 61% of the cost of living in a nursing facility. This calculation is based on the following analysis which compares the monthly Medicaid reimbursable cost for a Texas nursing home resident with the cost of Medicaid recipients who participated in the Money Follows the Person program.  The Texas Medicaid rates (http://www.hhsc.state.tx.us/rad/long-term-svcs/downloads/2014-nf-rates.pdf) assume that each nursing facility provides institutional care to Medicaid eligible recipients including the total medical, social and psychological needs of each client, including room and board, social services, over-the-counter drugs, medical supplies and equipment, and personal needs items. There are 36 unique, diagnosis related daily reimbursement rates. Additional daily reimbursable costs were added for patient liability (1.48), general liability (.13) and additional level of care (level 27=10.53). The average per diem rate was $131 and the average monthly reimbursement rate was $3,937 assuming 30 days in each month.  
     
    For MFP costs, Table 1 in Irvin et al. (2012) shows the costs for MFP participants in multiple categories. Excluding those with Intellectual Disabilities (n=1,466) and Unknown disabilities (n=269), the average, weighted cost per month was $2,407. This cost includes all Medicaid reimbursable costs. This figure represents 61% of the comparable Nursing home per person per month cost.
     
    References
     
     Irvin, C. V., Bohl, A., Peebles, V., & Bary , J. (2012), Post-Institutional Services of MFP Participants: Use and Costs of Community Services and Supports.  THE NATIONAL EVALUATION OF THE MONEY FOLLOWS THE PERSON (MFP) DEMONSTRATION GRANT PROGRAM: R E P O R T S F R O M T H E F I E L D (Vol. 9). Mathematica Policy Research.
     
  • UT Austin video 10:10 - end
  • Some people have been out up to 6 years

    Return to the NF is one factor, but not the only one. We do not express the outcome as an either/or but as days or years of institutionalization averted or reduced. Even if some people return over time that may not in itself always be a negative outcome. It could be a choice for some people, but at least a real and not a forced choice.
  • New Directions in Medicaid - Initiatives for People with Mental Illness

    1. 1. New Directions in Medicaid Initiatives for People with Mental Illness Dena Stoner, Senior Policy Advisor Texas Department of State Health Services
    2. 2. The Most Dangerous Phrase in the English Language “We’ve Always Done It This Way” 2
    3. 3. 3 Innovation Cycle
    4. 4. Medicaid Opportunities • Demonstrations - Money Follows the Person Behavioral Health Pilot • State Medicaid Plan Options – Home and Community-based Services for People with Severe Mental Illness • Grant Opportunities – Incentives for Prevention of Chronic Disease 4
    5. 5. Why focus on Mental Illness? • Mental illness has costly human and financial consequences • Texans with severe mental illness live 29 years less than other Americans and have more health problems earlier in life. • Mental health and substance abuse conditions comprise 9 percent of initial Texas Medicaid initial inpatient admissions but represent 27 percent of potentially preventable readmissions. • Institutional care in state mental health hospitals costs the state $500 or more dollars per day. 5
    6. 6. Money Follows the Person Behavioral Health Pilot (MFP BH) 6
    7. 7. The Challenge • National data indicated that large numbers of nursing facility residents have a primary diagnosis of mental illness, with a disproportionate number being under the age of 65. • In 2007, over 7,000 Texas nursing facility residents were former clients of the mental health system. • People with mental health and substance use disorders experience special challenges in returning to the community. 7
    8. 8. Video: In the Nursing Home 8
    9. 9. The Opportunity • 2008- Texas awarded MFP demonstration grant, funded by the Centers for Medicare and Medicaid Services • The grant allows Texas to test innovations, including the Behavioral Health Pilot 9
    10. 10. MFP BH Pilot Goals • Transition adults with severe mental illness and/or substance abuse disorders from nursing facilities to the community • Help people be successful in the community by integrating mental health and substance abuse services with long term care services and supports • Result in positive, long-term changes to the Medicaid system 10
    11. 11. BH Pilot Scope • Includes adults with mental health or substance use conditions and functional limitations who have resided in a nursing facility for 3+ months. • Two pilot sites in San Antonio (Bexar County) and Austin areas. • Partnership of State’s Medicaid, Mental Health and Long Term Care systems. 11
    12. 12. BH Pilot Services • Coordinated with other services provided through Medicaid managed care • Pre-Transition Services - up to six months before discharge to help prepare for community life. • Post-Transition Services - up to one year of Pilot services post-discharge • Transition plan – to regular Medicaid services and community resources 12
    13. 13. Cognitive Challenges • Apathy – A person does not start necessary activities on their own or does not complete all the steps • Disinhibition – A person acts in a way that is not appropriate to a situation, gets easily distracted, or behaves very impulsively • Mixed – Both challenges present 13
    14. 14. Cognitive Adaptation Training (CAT) • Evidence-based psycho-social intervention • Uses a motivational strengths perspective to facilitate person’s initiative and independence • Provides environmental modifications (e.g., calendars, clocks, signs, organizers) to help people bypass cognitive challenges and organize their environment and function independently 14
    15. 15. Organizing Activities Sam’s Daily Checklist MON TUE WED THU FRI SAT SUN Charge phone Use Deodorant Put on shoes Put on clean shirt 15
    16. 16. Adaptations 16
    17. 17. Organizing the Environment 171717 Apathy Disinhibition Mixed
    18. 18. Compensating, Not “Curing” Executive Function Attention Memory Psychomotor Speed Performance of ADL’s Social Function Occupational FunctionCAT Compensatory strategies Environmental supports 18
    19. 19. CAT Intervention Categories • Hygiene • Medication Management • Orientation • Money Management • Transportation • Eating/Nutrition • Cooking • Toileting • Dressing • Housekeeping • Social Skills • Stress Management • Vocational Skills 19
    20. 20. Substance Use Services • Assessment • Individual & Group Counseling • Tobacco Cessation Counseling • Peer Support • 24-hour On-Call Support • Motivational Interviewing • Harm Reduction • Person-centered care planning • Interdisciplinary team approach 20
    21. 21. Participant Characteristics • Average Age was 59 (range 26-89) • 54% are female • 29% Hispanic, 17% African American, 52% Anglo • 72% with serious mental illness (28% with other mental illness or substance misuse) • 5% with dementia 21
    22. 22. Functional Measures • The Quality of Life Scale (QLS) (21 items) was developed to evaluate deficit symptoms and impaired functioning in people with schizophrenia. • The Multnomah Community Ability Scale (MCAS) (17 items) measures the functioning of chronically mentally ill persons living in the community. • The Social and Occupational Functioning Assessment Scale (SOFAS) is a single item that measures an individual’s level of social and occupational functioning resulting from mental and physical health problems. 22
    23. 23. 23
    24. 24. 24
    25. 25. 25
    26. 26. The Pilot Today • Over 291 people have been served since 2008 • Approximately 70% of BHP participants served remain in the community up to 5 years. • Examples of increased independence include getting a paid job at competitive wages, driving to work, volunteering, getting a GED, teaching art classes, leading substance use peer support groups and working toward a college degree. • After initial relocation expenses, the Pilot annually saves Medicaid money since community care costs about 40 percent less than nursing facility care. • Overall impact of program appears strong with additional data being collected to expand analysis. 26
    27. 27. The Future • Managed care organizations will provide Medicaid rehabilitative and case management services for people with severe mental illness. (They already provide substance abuse and other mental health services.) • Texas could include the Pilot’s evidence-based practices in its managed care system. Thousands of Texans could benefit. • Texas is sharing results nationally to inform federal policy changes that support independence, recovery. 27
    28. 28. Video: A New Beginning 28
    29. 29. MFP-BH Return to NF Outcomes • Medicaid data showing nursing facility stays were obtained for 213 participants to determine whether they were still in the community. • 150 or 70% of participants remained in the community o Median tenure was 24 months o Longest tenure was 65 months o Total community time in years for group is 314 years • Over 50% of those who returned to nursing facility (n=63) were in community for 24 months or longer; Total time in community was 76 years 29
    30. 30. Home and Community-based Services – Adult Mental Health 30
    31. 31. The Challenge • Some adults who have severe mental illness experience extended inpatient commitments – sometimes lasting for years • These individuals have very complex needs – cognitive, physical, social • They require individualized home and community-based services (HCBS) to successfully attain and maintain independence • They could not get HCBS services through existing waivers or Money Follows the Person because of Medicaid regulations (IMD exclusion) 31
    32. 32. The Opportunity • 1915(i) of SSA enables states to provide HCBS under a Medicaid state plan amendment • Can target a broad range of customized services to populations such as adults with SMI, which are not otherwise available under Medicaid (e.g. residential supports, respite care, transition assistance, specialized therapies, peer support) • Rider 81: pursuing 1915(i) amendment for adults with complex needs and very long, repeated stays in psychiatric hospitals • A complex, but worthwhile endeavor! 32
    33. 33. Moving Upstream: Incentives for Prevention of Chronic Disease 33
    34. 34. The Challenge • The leading causes of death for people with severe mental illness are chronic health conditions such as heart disease, cancer and lung disease. Despite overall declines in cigarette smoking, a high prevalence of smoking persists among Americans with mental illness. • Taking atypical antipsychotic medications puts an individual at risk for developing type 2 diabetes. • Alcohol misuse is one of the greatest risk factors for the development of some cardiovascular diseases, cancer, chronic lung diseases, and diabetes. 34
    35. 35. The Opportunity • Texas awarded a Medicaid Incentives for Prevention of Chronic Disease (MIPCD) Federal Grant • Texas MIPCD study is known as WIN (Wellness Incentives and Navigation) • Large Randomized trial in Harris SDA (1250+ adult SSI participants), operating through December 2015 • Provides evidence-based incentives to help Medicaid clients adopt healthy behaviors, improve outcomes • STAR+PLUS is Texas Medicaid’s dominant health care delivery system for adults with disabilities. Potential for large scale impact, if successful. 35
    36. 36. 36 36 WIN Interventions • Person-centered wellness planning with professional health navigators, who are trained in Motivational Interviewing (MI) techniques. • Flexible wellness account to support specific health goals defined by the participant in the individual wellness plan. ($1150 / yr., administered through the navigator) • Wellness Recovery Action Planning training (WRAP) to enable participants to better manage mental and physical challenges.
    37. 37. WIN Features • Rapid cycle improvement process • Partnership: Stakeholder Advisory Group, Medicaid Office, Medicaid MCOs • Uses technology to collect data, reach participants and manage workload • Tracks outcomes including weight, BMI, clinical indicators (e.g., HBa1c) health care utilization, engagement in interventions, satisfaction, costs 37
    38. 38. The Goal • People with mental illness less likely to become or remain institutionalized • People with behavioral health conditions will be able to manage their physical and mental health. 38
    39. 39. 39
    40. 40. Contact Information Dena Stoner, Senior Policy Advisor Texas Department of State Health Services dena.stoner@dshs.state.tx.us 40

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