Mental Health: Network Design Celeste Putnam Deputy Secretary Substance Abuse and Mental Health Jeb Bush Governor Lucy Hadi Interim Secretary PROPOSAL FOR DISCUSSION ONLY Draft 10/11/2004

2 Current Public Mental Health System DCF/ADM contract enables providers to enroll as Medicaid mental health providers. Each provider can serve clients moving in and out of eligibility. This results in congruent provider system and but there are no managing entities to organize into single system of care. The department must manage 590 individual contracts. Providers report performance and outcome data to the department on both Medicaid and department funded clients. The department monitors agencies that are both Medicaid and department providers. DCF/ADM Contract for Services AHCA – Medicaid Payment for Services Data Monitoring $$ Provider

3 Separate AHCA - DCF System without Networks Multiple administrative costs. Inability to share in workforce development. Fragmented services. Very difficult for consumers/child/family to navigate. Loss of safety net concept due to fragmentation. Potential cost shifting. Decreased capacity for achieving uniform clinical policies and installation of “best practices.” Potential loss of uniform client level data reporting and related quality improvement initiatives. AHCA/Single Entity by Area Mental Health by Districts Prepaid Behavioral Health Plan Provider HMOs Provider Non-AHCA/DCF Services Housing Coalitions  Medical (non-Medicaid eligible Vocational Rehabilitation  Generic Support Education

4 Separate AHCA - DCF System with Networks Introduces managing entities but results in potential system fragmentation among multiple managing entities–system is still hard to navigate for clients. Higher costs related to multiple small risk pools and multiple managing entities – less $ for services. Loss of safety net concept due to fragmentation. Potential for increased cost shifting between entities. Decreased capacity for achieving uniform clinical policies and installation of “best practices.” Potential loss of uniform client level data reporting and related quality improvement initiatives. HMOs AHCA/Medicaid AreaDCF/ADM District CBC Prepaid Behavioral Health Plan Provider Managing Entity Non-AHCA/DCF Services Housing Coalitions  Medical (non-Medicaid eligible Vocational Rehabilitation  Generic Support Education

5 AHCA –DCF Integrated System AHCA contracts with DCF to manage an integrated system of behavioral health care for DCF clients and Medipass recipients. (70% of adults with severe and persistent mental illness and children with severe emotional disturbance are enrolled in Medipass.) Federal Medicaid administrative match funds could underwrite this added management capacity. DCF and AHCA would have complementary funding contracts with the same single managing entity in each area. ADM district offices would organize around AHCA regions. The combined ADM/AHCA system will remain the “safety net” for public sector clients. Clients receive same services regardless of payer. This managing entity would create a seamless system of care for high need clients moving in and out of Medicaid eligibility. An Active consumer panel guides and informs the managing entity. HMOs DCF District Single Behavioral Health Managing Entity Provider AHCA/Medicaid Area Management Contract $ $ $ Compliance/TA/Service Coordination Non-AHCA/DCF Services Housing Coalitions  Medical (non-Medicaid eligible Vocational Rehabilitation  Generic Support Education

6 Benefits of an Integrated System The Use of a single managing entity enables the Department to contract for all publicly funded and mental health services. Contracting with the same managing entity promotes: QUALITY INCREASED ACCESS COST-EFFECTIVENESS

7 Quality Increases Clinical Standards - Standard expectations for providers about credentialing, training, use of clinical protocols, serve to raise the clinical bar and enhance access, quality, treatment and improve satisfaction by recipients and their families. Promotes Implementation of Evidence-Based and Promising Practices – Common standards for all network providers means the Department can require network providers to implement current best practices (Example – District 1 implementation of FALGO medication algorithm and the Minkoff Co-Occurring model). Increases Promotion of Recovery-Oriented Services –With all network providers operating under a common set of values and principles that drive treatment decisions, comes an expansion of cost-effective, community-based recovery services and supports that promote community living and recovery of individuals with serious mental illnesses. Strengthens Recipient and Family Involvement – Common values and principles that support recipient and family member involvement in decision making in all aspects of the service system leads to greater acceptance of policy decisions and reduces complaints. The managing entity’s role in interfacing with recipients and their families on issues results in swifter resolution and promotes an opportunity for recipient and family education on key areas such as Advanced Directives.

8 Quality Enhances Integration of Care – The use of a single managing entity provides the framework for service integration. Integration of health care, mental health is enhanced with uniform eligibility criteria and a more comprehensive array of services and supports. Increases Partnerships – The Department can specify the terms of agreements with other system partners, such as law enforcement, jails and the Court system. These partners have come to expect certain services and supports for persons they refer to the publicly-funded mental health system. Increases Quality of Services – The refinement of common values and principles allows for the development of a network management plan for quality improvement and quality assurance consistent with the Department’s goals and objectives, rather than simple adherence to accrediting body standards that may not reflect Departmental priorities. The network QA/QI plan provides a mechanism for structured clinical monitoring that is ongoing, and enables the Department to trouble-shoot clinical issues for more immediate response. Provides for Comprehensive Data and Data Analysis – The Department would be able to require that data for all publicly funded services be reported to the Department’s One Family Mental Health data system. This will allow for the comprehensive and continuous analysis of data for timelier, less costly, more proactive system improvements to better meet recipients’ needs.

9 Equal Access Creates Equal Access – The use of consistent access standards for all recipients regardless of funding source enhances access to public mental health services and supports (Citation – USF – FMHI 2003 Draft Report). Enhances Uniformity – The development of standard expectations among providers promotes uniform treatment of recipients. Ensures Compliance with Legislative Intent – State legislators that sponsored Senate Bill 1258 ( , F.S.) and Senate Bill 2404, envisioned an integrated behavioral health services delivery system. The use of a single managing entity overseeing a single network of mental health providers is consistent with legislative direction. Emphasizes Department Priorities – Uniform requirements help the Department ensure that individuals served by the public mental health system that are considered priority populations (children in the Department’s custody for example) are provided services regardless of funding mechanism. Recipients most at risk are those who need complex forms of care: children and adolescents, elders, persons with dual diagnoses and those involved in the criminal justice system (Citation – Center for Health Care Strategies Working Paper, August 2002).

10 Cost-effectiveness Reduces Costs to the State – The uniform application of managed care principles that promote access, quality of treatment and are cost-effective result in a more cost-effective system. Contracting with the same managing entity can lower overall administrative costs due to economies of scale. (Citation – USF –FMHI Evaluation of District 1). Reduces Administrative Costs for the Network Providers – Contracting with the same managing entity allows for more flexibility in the financing of services. This allows the managing entity to develop compatible financial, clinical and program structures for both Medicaid and SAMH funding, resulting in a reduction in associated administrative costs. Comprehensive data for all publicly-funded recipients will allow the Department to more accurately determine potential cost- shifting to the Department. It will also enable the Department to analyze the utilization of recipients receiving high cost services, such as state mental health treatment facilities and crisis stabilization units (CSUs). Effective use of limited staff – Allows staff to focus on effective and meaningful activities.

11 What about Substance Abuse? Should Substance Abuse be part of an Integrated System?  The Medicaid Single Entity does not include Substance Abuse.  Network selection would have been made without Substance Abuse criteria.  Leaving Substance Abuse outside of network creates greater fragmentation. Should Substance Abuse have a separate network linked with Mental Health?  A significant percent of persons have co-occurring disorders.  Medicaid will eventually capitate Substance Abuse.  Substance Abuse will be a smaller entity separate from larger more established networks.