New York’s Medicaid program serves over 5 million enrollees with a broad array of health care needs and challenges. The Medicaid program serves many population groups with complex medical, behavioral, and long-term care needs that drive a significant volume of high cost services including hospitalizations, inpatient stays and long-term institutional care. Appropriately accessing and managing these individuals through service integration and improved care coordination is essential to improving overall health outcomes and to controlling future health care costs for this population.
Integrated Licensure
Individuals with substance use disorders and mental illness often receive regular care in specialized behavioral health settings, but many do not access any basic primary care or routinely manage their chronic physical health conditions. When they do receive physical health care, it is often segregated from their behavioral health services leaving primary care practitioners unaware of the full scope of their patients’ healthcare needs. Likewise, individuals who are engaged with a primary care practitioner are frequently treated only for chronic and preventative medical issues, leaving behavioral health issues unaddressed and unidentified. This fragmented care causes many of these individuals to experience poorer health status and higher rates of emergency room visits and inpatient admissions.
New York State is seeking to reduce preventable inpatient stays and hospital utilization among people with substance use disorders, mental illness and chronic health conditions and improve their overall health status and quality of life by the co-location or programs which integrate physical health and behavioral health services.
The New York State Office of Alcoholism and Substance Abuse Services (OASAS), the Office of Mental Health (OMH), and the state Department of Health (DOH) have been working together on the Integrated Licensing Project. The key goal of this project is to facilitate the delivery of integrated care in outpatient clinic settings to improve the quality and coordination of care provided to people with multiple needs. Participating providers benefit from reduced administrative burden because their programs are monitored by one of the state agencies using integrated standards. A single clinical record, integrated program staff and one set of Medicaid billing rules all contribute to better care and less burden.
There are currently seven providers with fifteen sites participating as integrated clinics in the pilot stage of the Integrated Licensure Project. These providers are operating in different regions of the state under varying models. All models involve providing at least two of the three permitted services; substance use disorder treatment, mental health treatment, and primary care. The state agencies are gathering information and data from each provider’s programs that is being used to guide the expansion of this project.
To facilitate statewide expansion, the state agencies have begun drafting an integrated regulation that will be adopted by all three state agencies and provide a single comprehensive set of standards to guide provider application, survey requirements, service delivery, physical plant requirements, clinical delivery and billing. The regulation and associated expansion is slated to begin in early 2015.
Health Homes
While integration of behavioral health and physical health is a significant step towards improving care for individuals who suffer from multiple physical and behavioral health conditions; improving coordination among all service providers, including medical, clinical, supportive, and recovery-based organizations is another critical component to reducing the utilization of more costly inpatient and hospital services. Coordinating care is especially critical for those who suffer from more complex and/or chronic conditions, including substance use disorders and serious mental illness. Medicaid recipients who suffer from substance use disorder and another chronic condition or serious mental illness are eligible for enrollment in one of New York’s 32 health homes located throughout the state.
A health home is a care management service delivery model whereby all of a member’s providers and caregivers communicate with one another to ensure that the member’s needs are addressed in a comprehensive manner. The model recognizes that individuals often require more than medical services to maintain their health and recovery. Coordination of supportive services such as housing, peer supports, and recovery services are also critical to ensuring long term stability.
A health home member is assigned to a “care manager” who oversees and provides access to all needed services. Care managers engage their members in varying degrees of frequency and intensity to ensure that members receive whatever is necessary with the goal of staying healthy and out of emergency rooms and hospitals. Health records are shared among providers so that services are not duplicated or neglected, and providers are able to have a real-time, comprehensive understanding of a member’s needs.
Health home services are provided through a network of organizations that includes providers, health plans and community-based organizations. The designated health home provider is the central point for directing patient-centered care and is accountable for reducing avoidable health care costs. Where an inpatient or hospital stay occurs, the health home is also expected to provide timely post discharge follow-up to ensure connection to necessary aftercare, improve patient outcomes and avoid further readmissions.
The overall goals of the health home service delivery model are to lower rates of emergency room use, reduce hospital admissions and re-admissions, reduce health care costs, foster less reliance on long-term care facilities, and improve the experience of care and quality of care outcomes for the individual members.
While integrated licensure and health homes are only in their early stages, initial response is encouraging. It is only through system change and innovative new service delivery models such as these that New York will succeed in its goals of providing better care and reducing the state’s growing Medicaid expenditures.
