Behavioral Health Integration Work Group

November 14, 2011

Dual Eligible Planning Grant

On the call: Amelia Mahan, Bebe Smith, Marc Jacques, Jim Graham, Laurie Cocker, Don Herring, Heather Brewer, Kenny Burrows, Peggy Balak, Erica Arrington, Jody Riddle, Christal Kelly, Robin Huffman, Pat Gerney, Nidu Menon, Elise Bolda

Thanks to all for time invested!

Provider Participation Work Group update - began discussion today with consideration of implications relative to coordination with BC WAIVER (previously about licensed professionals and payment & billing)

See relatively few issues that are specific to dual eligibles

Credentialing

  • Hugeprocess – suggestion – createsa repository of credentialing forms where multiple MCOs can see original signature documents per requirements for URAC accreditation.
  • Seems doable – implications/complexity driven by prohibition of deeming.
  • Deemed status discussion is worthwhile – approach may need to be “here’s what we want in NC” and discussion of whether national or state accreditation will prevail (if accreditors are unwilling to help reduce time burden associated with this function).

Where do Dual Eligibles seek/get care?

  • A lot of this population goes into primary care – E&M codes for PCP now managed apart from E&M codes for NH
  • Need to be sure there are enough unmanaged visits allowed since dual get care from PCP
  • This will facilitate access to care – currently 22 visits for adults –
  • DMA BH Section talking about list of diagnoses that are exemptions to visit limits – may expand list of diagnoses to broaden –
  • Need consistency across MCOs (recognizing that the benefit package, level of care & LOS can be different)
  • PCPsare not going to be able to keep up with all the different packages of all the MCOS for dual eligible beneficiaries
  • Going to have to be cognizant of variations from county to county

From earlier discussions – need to have a clear timeline for submission of claims to address the varying limitations (e.g. 90 days vs 12 months to submit bills) and challenges of getting Medicare denial prior to billing Medicaid.

Discussed behavioral health needs of older adult (65+) duals

  • Need a recommendation around developing better protocols that address the integration issues
  • Recognize older duals are unlikely to start seeking care from new systems –need to figure that out and make it work better
  • There are various consultation models – not necessarily a lot of direct clinical models, embedded,
  • Need to keep in mind that MCOs are not direct care providers – they function more like an insurer
  • Need clinical direct care
  • Including care & education for family caregivers
  • Once care plan in place may be able to use lay & peer supports – families helping families
  • Best practices for geriatric population – not much out there
  • When talk about behaviors - there is training twice a year around dementia, need to include people with mental health conditions
  • Education on working with people with behaviors related to mental health conditions ex: for very depressed people, becoming isolated – not functioning, just as dangerous
  • Need to have protocols and payment – included rates or pay separately for time for linkage, referral & true consultation takes more time
  • Education for consumers around wellness – diabetes care is paid for – need same for education on wellness for BH needs to be paid for

Care providers need to get training and that also needs to be paid for

Considerations:

  • Need differential rates for people with better outcomes – good life outcomes – pay for outcomes instead of process
  • Cause & effect difficult to attribute – best outcome is needing no service at all Or less service need/use
  • Providers not required to understand model – frustrating – Know what a transition should look like, not willing to pay the incentive system – goal is to do less, we need to find out how to transition the clinical model & payment
  • Caution: Duals are not all interested recovery model – ex: dually eligible beneficiary with lung cancer and schizophrenia, care needs are not a recovery model question
  • Focus needs to be on quality of life changes
  • Discussion among family-to-family networks ask ‘Where do you find a psychiatrist that believes in recovery?’
  • Exit service – is needed to smooth transition from Intensive Outpatient -currently you are served, graduate and then have to be sucky enough to return to Intensive before you get any support
  • Pilot underway –Ramon Rojano Wake Human Services – FF 77 multiple hospitalizations – pilot –
  • Reminder - small numbers of people use huge chunks of services
  • Illness self-management requires cultural change
  • Training – updated current – at state level – providers can’t be asked to pay for the training
  • Many of these whole concepts we don’t get because people were bogged down in MH reform – too busy keeping up with new rule changes to read the literature
  • Need rehabilitation type training – currently consumers are gas lighted – told they are non-compliant if they try to move away from the service delivery system

Next Meeting on Calendar for November 28