1. Arizona Department of Health Services/Division of Behavioral Health Services Challenges and Innovation in Integrating Care Robert J. Sorce Assistant Director Arizona Department of Health Services Division of Behavioral Services June 29, 2011

2. Arizona’s Publically Funded Health Care System Arizona Health Care Cost Containment System (AHCCCS) Arizona Department of Health Services/Division of Behavioral Health (ADHS/DBHS) AHCCCS/Arizona Long Term Care System (ALTCS) Community Health Centers(CHC), – Federally Qualified Community Health Centers (FQHC) –Rural Health Clinics (RHC)

3. AHCCCS State Medicaid Agency Established in 1981 under Section 1115 demonstration waiver Oversees contracts with ten managed care health plans for the delivery of acute care services to Medicaid eligible members Reimbursement through capitated payments on a per member/per month basis As of June 2011, served approximately 1,200,000 members

4. ALTCS Administered by AHCCCS to provide long term care services to elderly and disabled Medicaid eligible members Oversees managed care contracts with nine program contractors Contractors provides full array of acute care and behavioral health care services Home and community based services keep members out of institutions

5. CHC FQHCs and RHCs provide primary health care to the indigent regardless of ability to pay Offer acute, behavioral and dental primary care services 16 sites throughout the state Reimbursed by AHCCCS, federal grants (HRSA) and self-pay

6. ADHS/DBHS “ Carve Out” to provide behavioral health services to Medicaid eligible members No direct service delivery except for Arizona State Hospital Oversees contracts with managed care organizations, Regional Behavioral Health Authorities and American Indian tribes to deliver services (RBHA)

7. ADHS/DBHS Contracts State is divided into six geographic service areas (GSAs) Four RBHAs serve the six GSAs Contracts are bid on a 3-5 year competitive cycle Five Tribal Contractors

8. ADHS/DBHS Funding Fiscal Year 2010 Fund SourcePercent Title XIX87% TXXI1% Other Federal Funds3% Non-Title XIX General Funds6% County Funds3% Total Funding $1,403,355,525 100% *Funding information, 2008 Annual Report

9. ADHS/DBHS Funding Stream

10. ADHS/DBHS Populations Adults with Serious Mental Illness (SMI) Adults with General Mental Health/Substance Abuse Disorders (GMH/SA) Children

11. Populations…January 2011 PopulationsTitle XIX/XXI Non-Title XIX/XXI Total Children40,7373,75744,494 GMH/SA Adult 54,99611,26566,261 SMI Adult23,77211,48735,259 Total119,50526,509146,014

12. ADHS/DBHS Services Inpatient, medication, medication management, residential Support: case management, counseling, transportation, Home and Community Based Services: living skills, housing support, personal care Recovery: vocational, housing, peer support Crisis: statewide coverage, includes crisis phones, warm lines, mobile teams, inpatient psychiatric and detoxification facilities; operate 24/7, serves general public

13. Why Health Care Integration? Federal Health Care Reform Better outcomes; persons with SMI in Arizona die 25 to 30 years earlier than general population Control costs; 60 percent of Medicaid’s highest cost beneficiaries with disabilities have co-occurring physical and behavioral health conditions Focus on screening, prevention, early intervention, care management, patient education, wellness Current system is unsustainable Use of technology

14. First Steps in Planning for Integrated Care Met with stakeholders that practice integrated care Identified key system partners Developed structure to drive change Obtained funding for planning; Section 2703 Planning Grant Obtained support and commitment from Executive; key decisions made to move forward

15. Met With Stakehold ers CHCs, FQHCs—have been doing integrated care for decades RBHA/Health Plan partnerships Other states

16. Identified System Partners AHCCCS ADHS/DBHS RBHAs Health Plans Providers Members and Family members

17. Structure for Change; Planning Grant Formed Health Home Development Steering Committee: –AHCCCS and ADHS/DBHS are co-leads –Obtained Section 2703 Planning Grant to develop health home for the SMI in Maricopa County –Hired consultant to conduct data analysis –Specialty Health Plan for Maricopa County SMI to begin October 1, 2013

18. Elements for Specialty Plan/Health Home Fully integrated at administrative and service delivery level; no “carve out” Multidisciplinary team delivers acute and behavioral health services in a dedicated facility or as a virtual team Outcomes measured as a team; not individually Evidenced based practice for screening, prevention, wellness, care management, disease management and Recovery programs Coordinate care through technology and information sharing systems

19. Steering Committee-Next Steps Consultant—Data analysis –Acute care, behavioral health care, Medicare data; utilization; profiling; co-morbid conditions; poly- pharmacy Stakeholder input –Members and family members –Providers –Managed care organizations –System partners Defining services and outcomes

20. Steering Committee-Next Steps Deciding requirements for health homes Guidance from CMS Consultation with SAMHSA State Plan amendment for Health Homes Staffing, work plan, project management Request for Information Request for Proposal; drafting

21. Challenges Communication; transparency; messaging; buy- in and support Budget cuts; significant cutbacks in Medicaid EHR/EMR/HIE; technology; sharing of data Preserving Recovery in the health home model Workforce development; training Costs; billing codes; reimbursement Confidentiality; HIPAA; substance abuse regulations

22. More Challenges… Opt in/out; member choice Oversight and administering multiple systems; staffing shortages Licensing; credentialing; privileging Provider network development Lawsuits; past, present and future

23. Still More Challenges… Staying true to mission, vision and values…avoiding “scope creep” Meeting the timeline Peer and Family voice and participation in program design Anticipating and planning for the unexpected

25. Questions??? ADHS/DBHS Website: http://www.azdhs.gov/bhs AHCCCS Website: http://www.azahcccs.gov http://www.azdhs.gov/bhs http://www.azahcccs.gov

26. Contact information Robert J. Sorce Assistant Director Arizona Department of Health Services Division of Behavioral Services 150 North 18th Avenue, Suite 200 Phoenix, AZ 85007 (602) 364-4628 - office (602) 364-4570 - fax robert.sorce@azdhs.gov robert.sorce@azdhs.gov