National Association of Medicaid Director’s Fall Conference Behavioral Health Integration in the Medicaid Program Blake Fulenwider Deputy Commissioner Chief, Medical Assistance Plans November 14, 2018

FY 2018 Medicaid Expenditures and Enrollment by Program ABD is 25% of the population and 59% of the cost LIM is 69% of the population and 39% of the cost PCK is 6% of the population and 2% of the cost Note: Includes CHIP

FY 2018 Medicaid Expenditures and Enrollment by Delivery System CMO members are 66% of the population and 37% of the cost FFS members are 34% of the population and 63% of the cost Note: Includes CHIP

Medicaid Rehab Option FY 2018 Expenditures and Top 10 Services CMO members are 28% of the Medicaid Rehab Option cost FFS members are 72% of the Medicaid Rehab Option cost

Medicaid Rehab Option Integration Opportunities in BH Services Physician/Psychiatric Treatment allows: Evaluation and assessment of physiological phenomena (including comorbidity between behavioral and physical health care issues). Nursing Assessment and Care allows: Observation, monitoring and care for the physical, nutritional, behavioral health and related psychosocial issues, problems or crises. Assessment and monitoring medical and other health issues that are either directly related to the mental health and substance related disorder, or to the treatment of the disorder (e.g. diabetes, blood pressure issues, substance withdrawal symptoms, seizures, etc.) Assertive Community Treatment (ACT) allows: Gaining access to necessary internal and external rehabilitative, medical and other services. Assistance to develop both mental illness and physical health symptom monitoring and illness self-management skills. A physical health management plan to be required as a programmatic goal The Majority of Behavioral Health-targeted Services are covered under the State Plan via the Medicaid Rehabilitation Option (MRO).

Medicaid Rehab Option Targeted Integration Services Clinical consultation, specifically designed to promote communication and coordination of health with other treating medical practitioners, allows: Coordination or revision of a treatment plan; and Understanding the complexities of co-occurring medical conditions on the individual’s behavioral health recovery plan (e.g. kidney failure, diabetes, blood pressure, etc.) Review of the individual’s progress for the purposes of collaborative treatment outcomes. Peer Support Whole Health and Wellness: Included under the Peer Support umbrella in the MRO and added as a result of prevention being added in the ACA to the Rehab definition. Provides coaching interventions to individuals to: Promote healthy lifestyles and to reduce identifiable physical health risks. Increase healthy behaviors intended to prevent the onset of disease or lessen the impact of existing chronic health conditions Teach more effective management techniques that focus on the individual’s self-management and decision making about healthy choices.

Peer Support Whole Health and Wellness Highlights and Outcomes Provided by Certified Peer Specialists (CPS) who have ad hoc specialized health training. Health training curriculum jointly designed between HHS agency partners: HRSA and SAMHSA. Must have an identified nurse supporter. Participants have shown significant improvement in: Patient activation than those in usual care and in rates of having one or more primary care visit intervention. Advantages were observed for physical health related quality of life, physical activity, and medication adherence. Decrease in cardiometabolic risk factors

Opportunities for Integration within Managed Care CareSource has interdisciplinary field teams (similar to the DBHDD ACT model). Teams include both medical and behavioral health specialists Identify unique needs of members Improve coordination, treatment compliance, and communication between their providers. Integration of behavioral health staff in the staffing model allows for increased opportunities to correlate physical and behavioral needs of members. 25% of care coordination staff have BH experience Provide mandatory mental health first aid class to all member- facing staff.

Strategies to address gaps and barriers Continued partnership with DBHDD, the state’s behavioral health authority. Out of clinic service delivery, allowable under the MRO and enables many services to be provided in other medical settings such as FQHCs, medical practices, etc. Limited usage, there hasn’t been an extensive adoption of this practice. Telemedicine Broad array of allowable services. Every Community Service Board (CSB) in the state has telemedicine capacity.