1. Missouri’s Primary Care and CMHC Health Home Initiative
Samar Muzaffar, MD MPH
Missouri Department of Social Services
MO HealthNet Division
Medical Director

2. Overview
Two Medicaid Health Home initiatives- primary care and mental health
Partnership between MO HealthNet and Department of Mental Health
Collaboration with Missouri Primary Care Association (MPCA), Missouri Hospital Association (MHA), Missouri Coalition of Community and Mental Health Centers
Multipayer Initiative coordinated by Missouri Foundation for Health (MFH)
One Learning Collaborative for all participants
Collaboration between MFH, Health Care Foundation of Greater Kansas City, MPCA, and MHA

3. Overview
Missouri is the first state to have both mental health and primary care CMS approved State Plan Amendments
A unique aspect of the program is the integration of behavioral health with primary care and vice versa in its structure.
Literature speaks to the centrality of appropriately and effectively managing behavioral health conditions in the management of physical health conditions
By implementing the health home program we hope to demonstrate
Reduced inappropriate ED utilization
Reduced avoidable in-patient utilization
Improved patient outcomes
Reduction in health care costs

4. Overview Key Health Home Services for MO:
Comprehensive Care Management
Care Coordination
Health Promotion
Comprehensive Transitional Care
Individual and Family Support Services
Referral to Community and Social Support Services

5. Missouri’s Health Homes
Primary Care Health Homes (24)
19 Federally Qualified Health Centers (FQHCs)
5 Public and Private Hospitals
Includes 14 Rural Health Clinics
~18,800 patients enrolled in October
CMHC Healthcare Homes (29)

6. Primary Care Target Population
Clients are eligible for a Primary Care health home as a result of having two chronic conditions; or having one chronic condition and being at risk for a second chronic condition. To be eligible patients must meet one of the following criteria
Have Diabetes
At risk for cardiovascular disease and a BMI>25
Have two of the following conditions
COPD/Asthma
Cardiovascular disease
BMI>25
Developmental Disability
Use Tobacco
At risk for COPD/asthma and cardiovascular disease

7. Primary Care Health Homes
Provide primary care services, including screening for, and “comprehensive management” of, behavioral health issues
Ensure access to, and coordinate care across, prevention, primary care, and specialty medical care, including specialty mental health services
Promote healthy lifestyles and support individuals in managing their chronic health conditions
Monitor critical health indicators
Divert inappropriate ER visits
Coordinate hospitalizations, including psychiatric hospitalizations, by participating in discharge planning and follow up

8. Initial Provider Qualifications
Utilize interoperable registry
Input annual metabolic screening results
Track/measure care
Automate care reminders
Produce exception reports
MOU with regional hospital or system within 3 months health home service implementation

9. Initial Provider Qualifications
Meet state’s minimum access requirement including enhanced access requirement
Have a formal and regular process for patient input
Have completed EMR implementation/use EMR for at least 6 months prior to beginning health home services
Actively use MHD EHR for care coordination & Rx monitoring

10. Initial Provider Qualifications
Substantial percentage of patients enrolled in Medicaid (> 25%)
Special consideration to those with considerable volume of needy individuals
Strong, engaged, committed leadership
Meet state requirements for patient empanelment

11. Primary Care Health Home Basics
Practice site physician or nurse practitioner-led
Health Team
Primary care physician or nurse practitioner
Behavioral health consultant
Nurse care manager
Care Coordinator
Others per practice

12. Health Home Team Members
Health Home Director 1:2500
Nurse Care Manager 1:250
Behavioral Health Consultant 1:750
Care Coordinator 1:750

13. Health Home Team Members
Staffing ratio development
PMPM development
Team member roles and training

14. CMHC Health Homes 29 CMHC Health Homes
17,882 individuals auto-enrolled
3203 children and youth (18%)
CMHC consumers with at least $10,000 Medicaid costs
~18,300 enrolled in October

15. CMHC Health Homes Target Population
Clients eligible for a CMHC health home must meet one of the following three conditions
A serious and persistent mental illness or serious emotional disorder
A mental health condition and substance use disorder
A mental health condition and/or substance use disorder and one other chronic health condition

16. CMHC Health Homes Target Population
Chronic health conditions include:
Diabetes
Cardiovascular disease
Chronic obstructive pulmonary disease (COPD)
Asthma
Chronic bronchitis
Emphysema
Overweight (BMI >25)
Tobacco use
Developmental disability

17. CMHC Health Homes
Provide psychiatric rehabilitation, including screening, evaluation, crisis intervention, medication management, psycho-social rehabilitation, and community support services
Embody a recovery philosophy that respects and promotes independence and responsibility
Complete a comprehensive health assessment
Monitor critical health indicators

18. CMHC Health Home
Assure access to, and coordinate care across prevention, primary care (including assuring consumers have a PCP) and specialty medical services.
Promote healthy lifestyles and support individuals in the self-management of chronic health conditions
Coordinate/monitor ER visits and hospitalizations, including participating in discharge planning and follow up

19. CMHC Health Homes Health Home Director 1 per 500 enrollees
Nurse Care Manager 1 per 250 enrollees
Primary Care Physician Consultant 1 hr/enrollee
Care Coordinator/Clerical 1 per 500 enrollees

20. CMHC Health Homes HCH Team Members
Health Care Home Director
Primary Care Consulting Physician
Nurse Care Managers (NCM)
HCH Clerical Support Staff
Community Support Specialists (CSS)
Psychiatrist
QMHP, PSR and other Clinical Staff
Peer Specialists
Family Support Specialists

21. Integration of Behavioral Health and Primary Care
The two health home programs coordinate behavioral health and primary care health needs:
PCHH’s coordinate primary care and behavioral health needs through the embedded behavioral health consultant
CMHC HH’s coordinate primary care and behavioral health through the embedded primary care physician consultant and the nurse care manager
Much of the effort, education, learning, and work, including The Learning Collaborative, has been around how to successfully integrate and coordinate the primary care and behavioral health

22. Questions? Missouri Health Home Website information: