1. New Directions in Medicaid Initiatives for People with Mental Illness Dena Stoner, Senior Policy Advisor Texas Department of State Health Services

2. The Most Dangerous Phrase in the English Language Weve Always Done It This Way 2 3. 3 Innovation Cycle 4. Medicaid Opportunities Demonstrations - Money Follows the Person Behavioral Health Pilot State Medicaid Plan Options Home and Community-based Services for People with Severe Mental Illness Grant Opportunities Incentives for Prevention of Chronic Disease 4 5. Why focus on Mental Illness? Mental illness has costly human and financial consequences Texans with severe mental illness live 29 years less than other Americans and have more health problems earlier in life. Mental health and substance abuse conditions comprise 9 percent of initial Texas Medicaid initial inpatient admissions but represent 27 percent of potentially preventable readmissions. Institutional care in state mental health hospitals costs the state $500 or more dollars per day. 5 6. Money Follows the Person Behavioral Health Pilot (MFP BH) 6 7. The Challenge National data indicated that large numbers of nursing facility residents have a primary diagnosis of mental illness, with a disproportionate number being under the age of 65. In 2007, over 7,000 Texas nursing facility residents were former clients of the mental health system. People with mental health and substance use disorders experience special challenges in returning to the community. 7 8. Video: In the Nursing Home 8 9. The Opportunity 2008- Texas awarded MFP demonstration grant, funded by the Centers for Medicare and Medicaid Services The grant allows Texas to test innovations, including the Behavioral Health Pilot 9 10. MFP BH Pilot Goals Transition adults with severe mental illness and/or substance abuse disorders from nursing facilities to the community Help people be successful in the community by integrating mental health and substance abuse services with long term care services and supports Result in positive, long-term changes to the Medicaid system 10 11. BH Pilot Scope Includes adults with mental health or substance use conditions and functional limitations who have resided in a nursing facility for 3+ months. Two pilot sites in San Antonio (Bexar County) and Austin areas. Partnership of States Medicaid, Mental Health and Long Term Care systems. 11 12. BH Pilot Services Coordinated with other services provided through Medicaid managed care Pre-Transition Services - up to six months before discharge to help prepare for community life. Post-Transition Services - up to one year of Pilot services post-discharge Transition plan to regular Medicaid services and community resources 12 13. Cognitive Challenges Apathy A person does not start necessary activities on their own or does not complete all the steps Disinhibition A person acts in a way that is not appropriate to a situation, gets easily distracted, or behaves very impulsively Mixed Both challenges present 13 14. Cognitive Adaptation Training (CAT) Evidence-based psycho-social intervention Uses a motivational strengths perspective to facilitate persons initiative and independence Provides environmental modifications (e.g., calendars, clocks, signs, organizers) to help people bypass cognitive challenges and organize their environment and function independently 14 15. Organizing Activities Sams Daily Checklist MON TUE WED THU FRI SAT SUN Charge phone Use Deodorant Put on shoes Put on clean shirt 15 16. Adaptations 16 17. Organizing the Environment 171717 Apathy Disinhibition Mixed 18. Compensating, Not Curing Executive Function Attention Memory Psychomotor Speed Performance of ADLs Social Function Occupational FunctionCAT Compensatory strategies Environmental supports 18 19. CAT Intervention Categories Hygiene Medication Management Orientation Money Management Transportation Eating/Nutrition Cooking Toileting Dressing Housekeeping Social Skills Stress Management Vocational Skills 19 20. Substance Use Services Assessment Individual & Group Counseling Tobacco Cessation Counseling Peer Support 24-hour On-Call Support Motivational Interviewing Harm Reduction Person-centered care planning Interdisciplinary team approach 20 21. Participant Characteristics Average Age was 59 (range 26-89) 54% are female 29% Hispanic, 17% African American, 52% Anglo 72% with serious mental illness (28% with other mental illness or substance misuse) 5% with dementia 21 22. Functional Measures The Quality of Life Scale (QLS) (21 items) was developed to evaluate deficit symptoms and impaired functioning in people with schizophrenia. The Multnomah Community Ability Scale (MCAS) (17 items) measures the functioning of chronically mentally ill persons living in the community. The Social and Occupational Functioning Assessment Scale (SOFAS) is a single item that measures an individuals level of social and occupational functioning resulting from mental and physical health problems. 22 23. 23 24. 24 25. 25 26. The Pilot Today Over 291 people have been served since 2008 Approximately 70% of BHP participants served remain in the community up to 5 years. Examples of increased independence include getting a paid job at competitive wages, driving to work, volunteering, getting a GED, teaching art classes, leading substance use peer support groups and working toward a college degree. After initial relocation expenses, the Pilot annually saves Medicaid money since community care costs about 40 percent less than nursing facility care. Overall impact of program appears strong with additional data being collected to expand analysis. 26 27. The Future Managed care organizations will provide Medicaid rehabilitative and case management services for people with severe mental illness. (They already provide substance abuse and other mental health services.) Texas could include the Pilots evidence-based practices in its managed care system. Thousands of Texans could benefit. Texas is sharing results nationally to inform federal policy changes that support independence, recovery. 27 28. Video: A New Beginning 28 29. MFP-BH Return to NF Outcomes Medicaid data showing nursing facility stays were obtained for 213 participants to determine whether they were still in the community. 150 or 70% of participants remained in the community o Median tenure was 24 months o Longest tenure was 65 months o Total community time in years for group is 314 years Over 50% of those who returned to nursing facility (n=63) were in community for 24 months or longer; Total time in community was 76 years 29 30. Home and Community-based Services Adult Mental Health 30 31. The Challenge Some adults who have severe mental illness experience extended inpatient commitments sometimes lasting for years These individuals have very complex needs cognitive, physical, social They require individualized home and community-based services (HCBS) to successfully attain and maintain independence They could not get HCBS services through existing waivers or Money Follows the Person because of Medicaid regulations (IMD exclusion) 31 32. The Opportunity 1915(i) of SSA enables states to provide HCBS under a Medicaid state plan amendment Can target a broad range of customized services to populations such as adults with SMI, which are not otherwise available under Medicaid (e.g. residential supports, respite care, transition assistance, specialized therapies, peer support) Rider 81: pursuing 1915(i) amendment for adults with complex needs and very long, repeated stays in psychiatric hospitals A complex, but worthwhile endeavor! 32 33. Moving Upstream: Incentives for Prevention of Chronic Disease 33 34. The Challenge The leading causes of death for people with severe mental illness are chronic health conditions such as heart disease, cancer and lung disease. Despite overall declines in cigarette smoking, a high prevalence of smoking persists among Americans with mental illness. Taking atypical antipsychotic medications puts an individual at risk for developing type 2 diabetes. Alcohol misuse is one of the greatest risk factors for the development of some cardiovascular diseases, cancer, chronic lung diseases, and diabetes. 34 35. The Opportunity Texas awarded a Medicaid Incentives for Prevention of Chronic Disease (MIPCD) Federal Grant Texas MIPCD study is known as WIN (Wellness Incentives and Navigation) Large Randomized trial in Harris SDA (1250+ adult SSI participants), operating through December 2015 Provides evidence-based incentives to help Medicaid clients adopt healthy behaviors, improve outcomes STAR+PLUS is Texas Medicaids dominant health care delivery system for adults with disabilities. Potential for large scale impact, if successful. 35 36. 36 36 WIN Interventions Person-centered wellness planning with professional health navigators, who are trained in Motivational Interviewing (MI) techniques. Flexible wellness account to support specific health goals defined by the participant in the individual wellness plan. ($1150 / yr., administered through the navigator) Wellness Recovery Action Planning training (WRAP) to enable participants to better manage mental and physical challenges. 37. WIN Features Rapid cycle improvement process Partnership: Stakeholder Advisory Group, Medicaid Office, Medicaid MCOs Uses technology to collect data, reach participants and manage workload Tracks outcomes including weight, BMI, clinical indicators (e.g., HBa1c) health care utilization, engagement in interventions, satisfaction, costs 37 38. The Goal People with mental illness less likely to become or remain institutionalized People with behavioral health conditions will be able to manage their physical and mental health. 38 39. 39 40. Contact Information Dena Stoner, Senior Policy Advisor Texas Department of State Health Services dena.stoner@dshs.state.tx.us 40