Excellence in Mental Health Act and the Emerging Health Reform Landscape (Moving from Sick Care to Health) Dale Jarvis, CPA

Last November I Spoke About… 1.Medi-Cal Expansion + Covered California. 2.New Behavioral Health $ Going to Medi-Cal Health Plans and Plans in the Exchange. 3.Broad Expansion of Drug Medi-Cal Benefits. 4.Major Changes in Short- Doyle Medi-Cal. 5.Integrated Care is becoming the Expectation. 2

Questions How many of you were at my session last November? How many of you have any recollection of what I spoke about? How many of you thought I was full of hot air? 3

Last November I Suggested… County MH & A&D Programs are no longer living in a bubble. (e.g. You no longer have a monopoly on the behavioral health money for the safety net population. What you do (or don’t do) affects risk-bearing health plans to a much larger degree than ever. 4 Key Idea!

And Pondered With You… Remember, your adult clients are the most expensive Medi-Cal enrollees in California. If you provide care that is dis-integrated, fragmented, or doesn’t achieve health outcomes… At-Risk health plans (Medi-Cal & Exchange) will lose money. 5

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The Evolution/Revolution Continues 1.Behavioral Health Centers of Excellence 2.Excellence in Mental Health Act 3.Section 2703 Health Homes Together these three initiatives will support the transformation of the U.S. and California’s behavioral health delivery system! 7

1. Behavioral Health Centers of Excellence 8

Why the BHCOE Project? “In health care, the days of business as usual are over.” “It’s time for a fundamental new strategy.” “We must… Shift the focus from volume to patient outcomes achieved Replace today’s fragmented system with a system in which services are concentrated in health-delivery organizations” 9

Our Journey: A Dozen Activities over 5 Months 10

Our Current BHCOE Definition A Behavioral Health Center of Excellence is known by the entire community as a great place to get care and a great place to work. A BHCOE offers easy access to affordable, comprehensive care for persons experiencing behavioral health issues. Clients experience respectful, self-directed, team-based, and holistic care that addresses their problems and achieves outcomes important to them. Excellence is created by each staff member who has a heartfelt connection to their community and the people they serve, Based on a deep understanding of trauma, best clinical practices, And an unshakable commitment to resiliency and recovery. 11

Our Current BHCOE Elements We have identified five elements… That we think will evolve over time. The following is not an exhaustive list, But we believe that organizations will not be viewed by the community as a great place to get care and a great place to work without getting high marks in all areas. 12

“Together pursuing the best we can imagine.” Easy Access (1) World Class Customer Service… Built on a Culture of Engagement and Wellness (2) 13

Are we seen as the Mayo Clinic of BH? 1. Healthcare Home/Physical Health 2. Prevention and Wellness 3. Engagement Services 4. Outpatient & Medication Services 5. Community and Recovery Support (Rehabilitative) 6. Other Supports (Habilitative) 7. Intensive Support Services 8. Out-of-Home Residential Services 9. Acute Intensive Services Comprehensive Care (3) With Care Management as the Connective Tissue 14

“Take responsibility for making sure I receive the best possible health care.” 1. The services are effective in achieving individual outcomes or system-wide outcomes; Excellent Outcomes (4) and Excellent Value (5) 2. The services are more cost-effective than alternatives that may have been selected; 3. The service are “lean,” meaning that waste (excess costs) have been removed through process improvement activities. 15

For more info, check out the paper henationalcou ncil.org/confer ence- 365/2014/05/ 09/centers-of- excellence- final-paper/ henationalcou ncil.org/confer ence- 365/2014/05/ 09/centers-of- excellence- final-paper/ 16

This all sounds pretty cool… But will it really happen and how do we pay for it? 17

2. Have you Heard about Certified Community Behavioral Health Clinics? 18

New Legislation passed by Congress on March 31,

Certified Community Behavioral Health Clinics Began life as Federally Qualified Behavioral Health Centers (FQBHCs), introduced at the 2010 National Council Conference in Orlando. Important strategy for achieving parity at the delivery system level (with FQHCs). Create a parallel structure with a single set of national standard that would serve as a blueprint for the Community Behavioral Healthcare Organization of the future. 20

What you need to know today about the new law Creates criteria for Certified Community Behavioral Health Clinics (by 9/1/2015). Part of the demonstration requires the use of an FQHC-like Prospective Payment System. (per encounter payment based on true cost.) Provides $25M to states to develop applications to apply for the CCBHC pilot (available by 1/1/2016). 8 states will be selected to participate in the 2-year pilot by 9/1/2017, receiving 90% FMAP for CCBHC services for the 2 years. 21

Nationally this is a REALLY BIG DEAL! The Secretary of DHHS has to submit recommendations to Congress by 12/31/2021 whether the demonstration programs should be continued, expanded, modified, or TERMINATED. i.e., the fate of parity in the community-based delivery system rests in the hands of the 8 state pilots. 22

For California this is also a REALLY BIG DEAL! Four Key Leaders in Congress were responsible for the legislation becoming law – Senator Stabenow (D) – Senator Blunt (R) – Representative Lance (R) – Representative Matsui (D) 23

3. Section 2703 Health Homes 24 The Affordable Care Act passed by Congress and signed into law by the president in March 2010, provides a variety of approaches to improving the U.S. healthcare system. Healthcare Homes Section 2703 of the Act allows states to amend their Medicaid state plans to provide Healthcare Homes for enrollees with chronic conditions.

Missouri is the first state to amend its Medicaid state plan to implement Healthcare Homes. Missouri will have two types of Healthcare Homes – Primary Care Chronic Conditions Healthcare Home Federally Qualified Health Centers (FQHCs) Rural Health Centers (RHCs) Physician practices – Community Mental Health Center Healthcare Home CMHCs and CMHC affiliates Paving the Way for Healthcare Homes Missouri’s Healthcare Homes Courtesy of the Missouri Department of Mental Health 25

The Missouri Model 26

Behavioral Health-Based Healthcare (The Missouri Model) Phase 2: The creation of Community Mental Health Center Healthcare Homes – A fundamental redefinition of CMHCs that expands the scope of service to include addressing the whole health needs of BH consumers: 1.Diabetes 2.Cardiovascular disease 3.Chronic obstructive pulmonary disease (COPD) Asthma Chronic bronchitis Emphysema 4.Overweight (BMI >25) 5.Tobacco use 6.Developmental disability 27

This looks a lot like many of California’s Integrated Primary Care/Behavioral Health Projects With two major differences: – It’s statewide. – There is a substantial amount of funding to support it – 90% FMAP for 8 quarters.

Behavioral Health-Based Healthcare (The Missouri Model) Missouri’s 26 Community Mental Health Center Healthcare Homes are not necessarily Primary Care Clinics. 29

Behavioral Health-Based Healthcare (The Missouri Model) They have a well defined model that has shifted the system from Case Management to Care Management and have brought medical professionals into the clinic to support the model. 30

Connecting the Dots The Bar is Being Raised. Mental Health and Substance Use Disorder Treatment Provider Organizations and Plans are now being expected to be part of the solution. Multiple initiatives are rolling out to support this transformation: – Integrated Care Initiatives – Care Coordination Pilots – Behavioral Health Centers of Excellence – Excellence in Mental Health Act – Section 2703 Health Homes County MH and AOD Programs and Plans are in the critical path of the fix! 31

Two Questions… Be Candid… How many of you will have any recollection in three months of what I spoke about today? How many of you think I am still full of hot air or, at least think that this has nothing to do with you and your county? 32

Other Questions and Comments 33