1. Presented by Beth Waldman, JD, MPH For the Iowa DHS Remedial Services Working Group Proposed Recommendations (Draft) December 3, 2010

2. 2 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Definition Definition of remedial services –There should be a definition of remedial services –New name: Behavioral Health Intervention Services –Definition to split into two separate services Community-based Behavioral Health Intervention Services Residential Behavioral Health Intervention Services –Definition shall include subcategories for specific services to be provided under this umbrella name, including: Health and Behavioral Intervention Rehabilitation Program Crisis Intervention Skill Development & Training Community Psychiatric Supportive Treatment

3. 3 Remedial Services Working Group; Proposed Recommendations (Draft) Definition: Community-based Behavioral Health Intervention Supportive directive and teaching interventions provided in a community-based environment that is designed to improve the individuals level of function as it relates to a mental illness within a primary goal of assisting the individual and his or her family to learn age appropriate ways to manage behavior and regain or retain self-control, including crisis stabilization services.

4. 4 Remedial Services Working Group; Proposed Recommendations (Draft) Definition: Residential Behavioral Health Intervention Services Supportive, directive and teaching interventions provided to children in a residential group care setting that go beyond services provided to all children in such a setting and that are designed to improve the childs level of functioning as it relates to a mental illness with a primary goal of assisting youth in preparation to transition to the community and learning age appropriate ways to manage their behavior and regain or retain self-control, including crisis stabilization services.

5. 5 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Admissions Criteria Admissions Criteria for Behavioral Health Intervention Services –Comprehensive assessment by LPHA for all services provided through Iowa plan, using guidelines (no standardized tool0 –Should usually be paired with clinical behavioral health services, but not absolute requirement –For community based remedial services, must have need for services that meet specific individual goals and are focused to (1) address behavioral support in the community, (2) address specific skills impaired due to a mental illness, (3) assist children at risk for out of home placement, or (4) transition back to community or home following out of home placement –For residential remedial services, must have need for services that meet specific individual goals and are focused to (1) address behavioral health support/skills in the childs environment or (2) assist children preparing to transition from group care setting back to the community

6. 6 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Provision of Behavioral Health Intervention Services Provision of Behavioral Health Intervention Services –LPHA to provide list of available community-based remedial services providers; group comfortable with potential for self-referral to same agency as could enhance coordination of care for members –Iowa Plan to develop Behavioral Health Intervention Services network prior to transition of services to the Iowa Plan –Iowa Plan credentialing standards for Behavioral Health Intervention Services providers shall include that providers have the following: Demonstrated infrastructure to appropriately monitor services being provided by staff Hiring practices that ensure staff meet minimum qualification levels (including some experience) Provide comprehensive training to staff Provide ongoing clinical support and supervision Promote collaboration with LPHA and remedial staff

7. 7 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Authorization for Services Model authorization for Behavioral Health Intervention Services after other authorizations within the Iowa Plan Provide live authorization- using a set of clear criteria for approval and a defined appeals process 15 minute phone call with LPHA to authorize single clinical treatment plan Iowa Plan will need to add staffing to process authorizations Reduce authorization over time, including total service units under a certain threshold or based on provider performance Still no authorization for other services included in the treatment plan

8. 8 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Program Integrity Program Integrity –Iowa Plan to send verification of services to random sample of clients –Require individual/parent signature on treatment plan and include requirement for frequency of contact with parent during services (e.g., monthly face to face contact) –Ongoing monitoring of utilization in aggregate –Ongoing training for providers –Endorse evidence-based practice and quality initiatives

9. 9 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Assuring Quality Behavioral Health Services Ongoing Education and Training Measurement –Member Outcomes –Provider Performance Standards and Measurement –Measurement within context of Iowa Plan

10. 10 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Ongoing Education and Training Should include multiple tracks – –Iowa Plan staff –Members –Providers Iowa Plan staff focus: –Addition of Behavioral Health Intervention Services to covered benefits under Iowa Plan When appropriate What other services used in addition (generally) Length of services –Cultural competency training When is in-home services appropriate/necessary given cultural background

11. 11 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Ongoing Education and Training for Members Iowa Plan should utilize a combination of culturally and linguistically appropriate written materials and Member sessions focused on: –Understanding the comprehensive set of services available through Iowa Plan and how to access those services –Understanding member responsibilities in receiving services –Understanding remedial services specifically, including goals of service, length of authorization, and how and when services are re-authorized Iowa Plan should update its member handbook to include Behavioral Health Intervention Services

12. 12 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Ongoing Education and Training for LPHAs Iowa Plan should provide a combination of written materials and trainings (including webinars and provider round tables) Topics to include: –Understanding comprehensive set of services covered through the Iowa Plan, including Behavioral Health Intervention Services –Understanding the Iowa Plans guidelines for assessment and Integrated Treatment Plan development and how to determine which services may work best for a particular individual –Understanding when and how to appropriately include Behavioral Health Intervention Services as part of an integrated treatment plan –Training on GAF –Cultural competency

13. 13 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Ongoing Education and Training for Behavioral Health Intervention Services Providers Iowa Plan should provide a combination of written materials and trainings (including webinars and provider rounds) Topics to include: –Understanding of how to tailor Behavioral Health Intervention Services to an individual based on that individuals specific needs and goals, as well as individuals family situation, and cultural and linguistic background –Understanding how to measure an individuals progress in meeting goals –Understanding what other services an individual is receiving and how remedial services fits into an overall plan of care; including coordination with other providers –Understanding of necessary components of individuals remedial services treatment plan –Understanding the connection between a needed skill and the mental health diagnosis –Understanding of how to use provider profiling reports to improve quality within the Iowa Plan and specific practice

14. 14 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Measurement of Member Outcomes Proposed Measures: –Increased number of members with comprehensive set of services (e.g., both clinical and remedial) –Increased level of members with overall treatment plan, including use of outpatient care –Improved health and functional outcomes Continue use of GAF scores to measure member outcomes of Behavioral Health Intervention Services Additionally, use CHI and CHI-C to make consistent with other Iowa Plan services Consider allowing other tools overt time (e.g., CANS, CAFIS)

15. 15 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Measurement of Provider Performance Standards Meet educational requirements set by the Iowa Plan Ongoing review of Individual Service Plans Tightened credentialing requirements Review of LPHAs and Behavioral Health Intervention Services Providers –Aggregate performance of individual providers Provider profiling on a quarterly basis as part of Iowa Plans QM Plan –Expand to include Behavioral Health Intervention Services –Compare across providers –Review aggregate GAF and CHI/CHI-C Scores –Review statewide trends Include Behavioral Health Intervention Services providers as part of the Iowa Plan QI review –One site visit per year, unless more needed due to corrective action plan

16. 16 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendations: Measurement of the Iowa Plan Require monitoring and improving Behavioral Health Intervention Services to be included as part of QM plan Measures should provide global review of the program and should mirror, to the extent possible, the performance requirements of the providers Include Behavioral Health Intervention Services as part of ongoing quality measurement within Iowa Plan Year 1: Monitor remedial services –Growth from current number of individuals receiving –Growth in number of individuals utilizing both clinical and remedial services –Other? Can do anything child welfare related here? Year 2: Ongoing monitoring; Incentives for performance that exceeds state set goals Year 3: Ongoing monitoring, Incentives for performance that exceeds state goals and Penalties for performance under state set floor Measure success of Iowa Plan working cooperatively with Juvenile Justice to reduce struggles across systems and improve coordination.

17. 17 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Behavioral Health Home Pilot Strategy Direct Iowa Plan to develop a behavioral health home pilot –Identify potential pilot sites with following characteristics: Provide full range of outpatient and remedial services Strong relationships with acute and psych hospitals, and PMICs Relationships (or willingness to build) with primary care providers –Develop clear definition for SED and focus on narrow population for treatment package –Provide technical assistance and support services towards practice change –Develop bundled payment with shared savings Include within funding assumption of on-site care management services Tie shared savings to meeting quality measurements –Explore ability to receive enhanced match as a health home under the ACA (see regulations issued November 2010)

18. 18 Remedial Services Working Group; Proposed Recommendations (Draft) Recommendation: Payment Strategy Rates will be paid on a fee for service basis based on a set fee schedule to be developed by the Iowa Plan –Will continue to pay on 15 minute units –No requirement to reconcile against costs –Different rates for home or office settings Allow Behavioral Health Intervention Services providers to receive incentive payments based on performance after first year; incentive payments tied to set of quality measures.