System Change and Service Providers: Opportunities and Challenges in Addressing Unmet Needs

In 2011, a priority of New York’s Governor Andrew M. Cuomo was Medicaid redesign, with the substantive presence of behavioral health services in both the Medicaid Redesign Team (MRT) and the subsequent Delivery System Reform Incentive Program (DSRIP). The focus was to reduce inpatient hospitalization and the over-reliance of the most expensive users of Medicaid on higher cost and avoidable services. Emerging from the effort was a lone outlier: children’s behavioral health services. The Behavioral Health Subcommittee of the MRT prudently decided not to apply the Triple Aim to the children’s mental health system and instead, identified that a separate Children’s Subcommittee was needed because: “The children’s behavioral health system of care was under-resourced and had insufficient capacity.”

Unlike every other MRT subcommittee, the Children’s Subcommittee was tasked in 2011 with expanding the children’s mental health service array and reforming delivery to address unmet needs and barriers to access. The redesign was still to include care management for all and conversion of Medicaid fee for services to Medicaid managed care, but the similarities with the adult service MRT efforts ended there.

In January 2019, New York will finally implement the recommendations of the MRT Children’s Subcommittee for Children’s Behavioral Health. The more than 7-year effort turned into a broad reform of the children’s system of care and goes beyond the need for more behavioral health services.

The children’s behavioral health reforms will:

  • Provide interventions earlier for more children by expanding the array of Medicaid services and expanding eligibility for certain services to more children;
  • Expand Medicaid spending on children’s behavioral health services; and
  • Address unmet need by reducing barriers and waiting periods for evaluations and accessing treatment.

The overall redesign effort will also:

  • Unify age eligibility across child-serving systems (foster care, mental health, developmental disability and medically fragile) to uniformly be from birth to age 21;
  • Offer care management for all eligible children;
  • Consolidate 6 existing but different Home and Community Based Waiver (HCBS) programs into a single HCBS array with 11 services; and
  • Move exempt populations and Medicaid services to Medicaid managed care.

The overall approach to the children’s system redesign was steeping in a long history. New York is home to two of the earliest federal 1915c Waiver program authorized in the United States: the Care-At-Home Waiver program for medically fragile children and the NYS Office of Mental Health’s Severely Emotionally Disturbed Waiver program for children who would otherwise need institutional or hospital level care. With a decade’s worth of history in caring for high-need, high-risk children in the community, New York’s providers were seen as leaders in serving children in the least restrictive environment. Therefore, when identifying which services could best support more children earlier in their illnesses, the MRT Subcommittee took the five most highly rates home and community-based services and proposed they be added to the state plan to be accessed by thousands more children.

Expanding the Array of Medicaid Children’s Behavioral Health Services: Three of the six new Child and Family Treatment and Support (CFTS) services will be added to New York’s State Plan on January 1, 2019. The new services are under Medicaid’s Early Periodic Screening, Diagnosis and Treatment (EPSDT) benefit and are available to children/youth under the age of 21 who are Medicaid-eligible and who meet medical necessity criteria. Previously, services similar to the CFTS services were only available to a very limited number of children with very complex needs who were eligible for HCBS services.

The CFTS service implementation will be phased in between Jan 1, 2019 and Jan 1, 2020. The January 1, 2019 changes include the addition of 3 of the 6 new CFTS services: Evaluation and Assessments and Psychotherapy – called Other Licensed Professions; Counseling and Psycho-social education – called Community Psychiatric Support and Treatment; and Skill-building and Rehabilitation – called Psychosocial Rehabilitation. In July 2019, another CFTS service will be added to support caregivers, and engage and strengthen families – called Family Peer Support Services. Later, on January 1, 2019, the last 2 CFTS services will be added to the Medicaid plan: Youth Peer Support and Crisis Intervention.

All six of the new services are intended to improve a child’s functioning at home, school and in the community and must be offered where children live, learn and play. The service design is for treatment and support to made available where the child and family can access it easily, as often as necessary and where the behavioral improvement are most necessary.

Designating Providers: The state determined that serving children in the least restrictive environments and with flexible, family-driven care, would not be as familiar to traditional brick and mortar based medical care providers. The designation process focused on the types of providers that were used to going to the children, not having the children come to them. Designation focused on those agencies already familiar with providing home and community-based services and providers with child, youth and family experience as well as clinical, licensed programs. Unlike previous community-based programs, like Early Intervention, individual practitioners will not be eligible for designation. The licensed and unlicensed care-givers will have to be employed by or under contract with a designated agency.

However, this approach to service delivery is not without challenges for service providers. In addition to having to establish regular, scheduled clinical supervision of a nomadic workforce, providers must recruit and retain a workforce able to wrestle with MTA delays or harsh weather conditions in upstate New York. In addition, the productivity of a travelling workforce brings expenses that may not be fully accounted for in the preliminary rates.

The general workforce shortages, a result of robust employment and in the clinical field, insufficient pipeline to meet demand, is a looming challenge.

The Children: All Medicaid eligible children who live in a home or community setting and meet medical necessity criteria and are able to accept flexible, family driven services can receive the CPST services. Medical necessity does require a diagnosis, but the addition of the Other Licensed Profession (OLP) service is intended to allow evaluations and assessments by licensed practitioners of the healing arts that can take place in community settings and be scheduled when family members are available.

Services for kids already receiving Medicaid service but who need additional supports to prevent the need for higher levels of care will also be eligible for the CPST services.

The opportunity to rapidly expand delivery of services to kids with unmet needs is the most exciting aspect of the children’s redesign.

Other Redesign Components: In addition to the expansion of community children’s behavioral health services, the reform that is planned for 2019 will include moving all youth in the 6 HCBS Waiver programs to Health Home care coordination. The transition from the current Waiver care coordination to Health Home care coordination is complicated and will require the existing HCBS Waiver providers to do a tremendous amount of work before January 18, 2019.

In addition, when the new array of HCBS services come on line in April 2019, the services and the children will be covered by Medicaid managed care. Then in July, the voluntary foster care population moves to Medicaid managed care. This will require Voluntary Foster Care Agencies to be enrolled with MMC plans for the first time. The system changes for the providers are extreme, but the quality results for children and families should be measurable almost immediately if more children access services and are linked into integrated record keeping and utilization can be tracked.

Next Steps and Measuring Success: To achieve the state’s vision of higher quality and more affordable care, the continued involvement of the Children’s MRT Subcommittee should be a priority throughout implementation. The state must ensure that reforms result in a behavioral health system that dramatically expands access to timely, high quality care, that the care management services meet family needs and that the new HCBS array is sufficient.

General Oversight Recommendations

  • Ensure that full funding to implement the new Children and Family Treatment and Support Services and the transition timeline of services to Medicaid managed care are met;
  • Evaluation whether the proposed reimbursement rates are sufficient to sustain the community-based design of the model and quality of the CFTS services;
  • Address the need for expanded workforce resources to build the needed clinical capacity to meet demand and address the significant shortage of qualified clinicians;
  • Collect data to assess the children’s behavior health implementation and utilization expansion under Medicaid Managed Care; and
  • Engage in a robust education and outreach campaign to ensure that pediatricians, family practices, and child- and family-serving agencies are aware of the new community-based options.

Data and Analysis Recommendations: Because most children’s mental health and behavioral health services were provided through capped and “slot-limited” programs, the comparison of Medicaid utilization will be an “apples to oranges” comparison for quite a few years. The capped programs are higher cost and fewer children were eligible, but as with any new service, the up-take on the CFTS services may be slow until public awareness pushes demand. Among the greatest challenges to determining the impact of the expansion of children’s behavioral health services is a lack of sufficient, comprehensive baseline data on the gap between the number of children who need behavioral health services, and those who actually receive them. Estimates on the gap between capacity and need remain frustratingly sparse, making it difficult to assess the true unmet need within the state. We therefore urge the state agencies involved with the children’s transition (Department of Health, Office of Mental Health, Office of People with Developmental Disabilities and Office of Children and Family Services) to collaborate to improve the collection and dissemination of data on children receiving behavioral health services. This effort must include establishing a baseline of children served prior to the transition, the state can better monitor the impact of these large systems changes. The data collection will identify how to best increase access in a strained and under-resourced system.

Workforce Recommendations: There is need for more data on workforce availability. Though we know the workforce shortages are widespread, it is difficult to quantify the extent of the problem without more robust data collection from the state. We support implementing a re-registry survey, requiring reporting and data collection on health care practitioners who seek to have their professional licenses renewed with the State Education Department. A program like this would allow licensed health and mental health care practitioners to report information including the type of setting where the practitioner practices and their geography. This data would help inform the state whether, where, and how behavioral health professionals are practicing, and help with specific health workforce shortages by targeting recruitment programs available through the state to the most under-capacity communities.

In addition, although the MRT initially made recommendations about addressing scope of practice reforms to address the behavioral health workforce shortages, they were never implemented. Moreover, while workforce training and transformation funding was readily made available to hospitals and other institutions, the community health care workforce was not the beneficiary of such investments. Now, with the expansion of children’s community services represents the perfect moment to re-establish a MRT Community Workforce Modernization subcommittee to tackle the community health and behavioral health workforce challenges that will ensure capacity expansion is possible.

Looking Ahead

As we ring in the New Year, let us rejoice in the opportunities as well as prepare for the challenges that lie ahead of us, as we strive to guarantee a better quality of care and services for our kids.

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