Each state manages its behavioral health system with different governance structures, agency involvement and legislative authority. The structures are often a legacy of history and legislation that was incremental in nature, adding oversight and new funding on top of older functions. With the changing landscape occurring in healthcare and public funding, now is an appropriate time to consider major change in governance. These examples describe alternatives that have enabled several states to manage Medicaid and non-Medicaid services through regional
Page | 179 authorities, requiring fewer state contracts and less direct oversight of individual providers, as well as new ways of thinking about interagency councils.
The statewide example discusses three states that have created high level coordinating agencies to reduce silos and rationalize bureaucratic structures. The two regional examples outlined below represent two different approaches states are implementing to manage their behavioral health services using Medicaid waivers and legislative authority.
• Statewide
o Interagency Councils. This description includes several states –Maryland, Massachusetts and New Mexico -- in which high level interagency councils or cabinets coordinate governance and/or funding of behavioral health services. The principle is that by mandating planning and policy coordination at the highest levels of state government, states can break down the “silos” within which programs traditionally operate and improve the efficiency and quality of care provided to individuals served. These are low cost strategies that can move a system forward or provide a foundation for more transformative change, as in New Mexico.
• Local Mental Health Authority
o The Arizona Division of Behavioral Health Services (DBHS) competitively bids and contracts with four Regional Behavioral Health Authorities (RBHAs) to serve six geographic service areas and four Tribal Regional Behavioral Health Authorities (TRBHAs) to provide Medicaid and non-Medicaid services to persons living in Arizona’s fifteen counties, including persons living on Indian reservations. RBHAs are not permitted to provide direct care covered services to any of the populations served under the DBHS contract.
o North Carolina LME-MCOs. In North Carolina, numerous Local Management Entities (LMEs) that were initially created to manage state and Block Grant funds for mental health authority behavioral health services, as well as carry out Medicaid enrollment and care monitoring functions, are now being merged into regionally based managed care organizations (MCOs) known as LME-MCOs. C. Advancing evidence-based and innovative clinical practices
This section describes four innovative clinical approaches that offer the potential of improving care to adults with severe mental illness and children with serious emotional disturbance. While they are quite different from one another, all suggest new approaches to clinical practice. There has been a great deal of attention to advancing the use of more evidence-based practices. The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a National Registry of Effective Programs and Practices (NREPP) that includes practices with demonstrated
Page | 180 effectiveness. SAMHSA is currently undertaking systematic reviews of the evidence on many of the major services in public behavioral health; these will start being released in the coming months. However, there has been limited success in statewide efforts to significantly increase the use of the most effective practices. One promising practice that was identified in the course of this work, but which is still emerging, is the “Distillation and Matching Model,” a process that is being used in several states including Hawaii and Minnesota. This model identifies common elements within evidence-based treatments and provides guidance to clinicians on the choices of different interventions and methods to monitor their efficiency. Because it is not yet at the point of being an evidence based practice and is extremely complex to implement, it is not discussed in detail here.
• Learning collaboratives have been used in New York78 and by the National Child Traumatic Stress Initiative to increase adoption of Wellness Self-Management. New York used a variation of Illness Management and Recovery while the National Child Traumatic Stress Initiative used trauma focused treatments. This type of training and research efforts important to continue. The example here is more systemic in nature and presents significant opportunities for Texas.
• Mental Health First Aid (MHFA) provides training to a broad group of individuals in communities, such as public health workers and teachers, in how to provide help to someone who may be in some form of mental health crisis. Recipients of MHFA intervention include people who might be depressed, anxious, psychotic, suicidal, using substances or suffering from trauma or panic attacks, among others. The goals are to increase the front-line capacity to recognize mental health conditions, to intervene appropriately and ultimately to reduce the stigma of these conditions.
• Peer crisis services are programs that are operated and staffed by consumers and designed to serve people in mental health crisis. The Living Room, as implemented in Maricopa County, Arizona by Recovery Innovations, is a crisis alternative within which an individual who is having a difficult time or is in crisis can become a “guest” and receive support from a team of Peer Support Specialists.
• Building Bridges is a national program, developed and managed under the auspices of the Center for Mental Health Services (CMHS), through which community and
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New York’s Office of Mental Health uses learning collaboratives to improve practices related to prevention of restraint and seclusion and wellness self-management, among others. See A. Salerno, P. Margolies, A. Cleek, M. Pollock, G. Gopalan, C. Jackson, “Best Practices: Wellness Self-Management: An Adaptation of the Illness
Management and Recovery Program in New York State,
Page | 181 residential treatment providers, policy makers and youth and families are working to improve communication and practice in residential and community-based treatment. D. Integrated Care – behavioral and primary/acute care services
The finding that individuals with mental health problems die as much as 25 years prematurely due to preventable ailments is a result in part of those individuals not receiving adequate primary health care services.79 The ACA builds on these findings and offers incentives for the development of Health Homes for specific populations including individuals with behavioral health issues. Health Homes integrate physical and behavioral health care services, thus helping to ensure that those with behavioral health problems receive needed primary care services. Also, Emergency Departments often see individuals whose illnesses or injuries are related to substance use. Screening, Brief Intervention and Referral to Treatment can lead such individuals to receive appropriate care.
• Missouri Health Homes. Missouri was the first state in the nation to receive CMS state plan approval for Health Homes for Individuals with Chronic Conditions. Health Homes were authorized by the Affordable Care Act, which allows states to receive increased federal funding (90% federal medical assistance percentage for eight consecutive quarters) for using specific health home services and technology to coordinate care across disciplines to Medicaid beneficiaries with one or more chronic conditions. Two other states have been approved (Rhode Island and New York) and as many as six other applications are pending.
• Colorado’s Medical Home Initiative (CMHI) began in 2001 in response to the Title V/ Maternal and Child Health goal and measure that all children will receive coordinated care in a medical home. This was a system building initiative that gathered parents, providers and other stakeholders to identify barriers and promote solutions for building and sustaining a system of quality healthcare for children.
• Massachusetts Screening, Brief Intervention and Referral to Treatment in Emergency Departments (ED SBIRT). Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based technique that involves systematic identification of people needing early intervention, engagement of those who screen positive in brief conversations about behavior change, and referral for comprehensive assessments and appropriate treatment when serious problems are found. It has proven to be particularly
79
J. Parks, D. Svendsen, P. Singer and M.E. Foti, Editors, Morbidity and Mortality in People with Serious Mental Illness, National Association of State Mental Health Program Directors (NASMHPD) Medical Directors Council, October 2006.
Page | 182 effective at motivating individuals to reduce or abstain from harmful substance use and seek treatment when they are not able to do this on their own. Emergency Departments (EDs) are significant points of contact for both substance use related injuries and illnesses. Data indicate that screening patients in emergency settings makes it possible to use their substance use-related injury or illness as motivation to change.
• Impact Team Care. IMPACT is a Team Care Model that emphasizes collaboration among the patient, primary care provider (PCP), a Depression Care Manager, and a consulting psychiatrist to effectively treat and improve outcomes for individuals with depression. IMPACT goes beyond co-location of services, achieving thorough integration of care.