Self-Direction in Medicaid for Well-being and Empowerment

Self-Direction in Medicaid for Well-being and Empowerment
By Briana Gilmore, Public Policy and Advocacy Director, NYAPRS
Self-direction is a strategy in organizing and delivering Medicaid-funded services and community supports that can dramatically enhance opportunities for people living with disabilities. The process transfers some of the funds typically afforded through Medicaid payments directly to the consumer, who develops a plan to utilize the money for services and supports for increased engagement and well-being. Hundreds of thousands of people experiencing developmental disabilities already utilize the approach, and many states have implemented or are seeking pilots to bridge the method to the behavioral health recovery community.
In New York, the Office of Mental Health (OMH) selected self-direction as a new service to implement through a Health and Recovery Plan (HARP) for Medicaid recipients with enhanced BH (behavioral health) needs. Implementing the program thoughtfully will take some careful planning; therefore the program will be piloted for a few years before being brought to scale statewide as a benefit for eligible recipients.
Any self-direction model must take into consideration the particular recovery needs of the community for whom it’s modeled. For people with physical needs, funds are often self-directed to health aides, house modifications, or other consistent supports. A model to support the behavioral health needs of a community must take into account social needs that span employment, education, community inclusion, well-being, and traditional rehab supports. New York is looking at an approach that would allow recipients to buy services like habilitation (services that help a person learn, keep, or improve skills and functional abilities that they may not be developing normally) and supported employment, but also direct funds to community wellness supports like gym memberships and yoga classes, college classes and bus passes.
The implications of self-direction are vast; it is the most flexible way for consumers to take ownership over their recovery and invest in chosen supports. The success of a self-directed recovery plan is largely dependent on the relationship between each recipient and a support broker, who is a chosen navigator that helps to maximize an individual budget. A recovery plan is based on current capacities and supports, and incorporates wellness goals for overall health. A recipient uses the plan as a tool to guide their spending. Purchases of traditional services and community supports are now typically made with smart debit cards that can track allowable services and be refilled directly by the payer.
There are many considerations that go into creating a self-directed design that benefits people with BH needs. The plan must take into account accessibility and enrollment processes, ensure culturally competent approaches, and allow for creative community-based solutions for enhanced well-being. The design must also plan for a relationship between a recipient-driven recovery plan, and a treatment plan that is supported by a Medicaid Managed Care Organization. Support brokers—who in most models are peer specialists or recovery-trained life coaches—should be supported by an infrastructure that can foster innovation and adaptiveness within the model. And ultimately, the financial process has to offer an efficient transfer of funds from the state Medicaid program.
I’ve been involved in a planning process with NYAPRS and the Columbia Center for Practice Innovations to help OMH develop a draft model for BH self-direction. The team has worked for eight months to review research, meet with experts in the field from around the country, and engage Medicaid recipients, DOHMH (dept. health mental hygiene), and other stakeholders to develop a strategy for implementation. The process will continue in the coming months as OMH explores the best framework and negotiates the process with other state agencies, Managed Care Organizations, and recipients.
NYAPRS (New York Association for Psych Rehab Services) has been advocating for a self-directed model in New York for nearly a decade. It’s exciting to know that the model could be offered to tens of thousands of Medicaid recipients with BH needs in the coming years. The state agencies, particularly through the Medicaid Redesign process, recognize that innovative approaches like self-direction can contribute to long-term savings and system benefits. These gains will be as a result of quality of life improvements like reduced hospitalizations and increased community engagement, as well as better overall satisfaction with the Medicaid program. A New York State pilot will include a strong research component to look at how recipients of different ages, backgrounds, and with different geographic living settings use and benefit from self-direction.
Barriers do remain, particularly in the appropriate financing of the approach. It’s also essential that appropriate protections be in place for both consumers and insurance companies before the design is implemented as a standard benefit. The design may provide a truly fundamental shift in Medicaid programming and consumer rights, if stakeholders on both sides continue to work together to actively improve the design through emerging best practices.
Look for opportunities in your area to participate in a self-direction pilot in 2015, as well as information about how you can get involved in the state’s planning process.

Medicaid Managed Care: Rising to the Challenge

Medicaid Managed Care: Rising to the Challenge

By Briana Gilmore, Public Policy and Advocacy Director, NYAPRS

During a recent forum where policy and business leaders met to publically discuss health care reform, Arthur Gianelli from Mt. Sinai hospital said that for the first time “Medicaid is at the vanguard of delivery system reform.” This statement is a sign of a big change in thinking as Medicaid becomes a new beacon of progressive change in New York State (NYS) and across the nation. The current expansions and experiments in our Medicaid program are driving change at every level: from member satisfaction, to service integration, to oversight of insurance companies and to quality incentives.

These changes have been in the spotlight since Governor Cuomo implemented the Medicaid Redesign Team in 2011. The Redesign Team started to engage experts—including consumer advocates—in a process to transform our expensive but low-quality service system.

An article I wrote in the spring edition of NYC Voices introduced integrated Medicaid Managed Care for people with behavioral health needs and a special option called a Health and Recovery Plan (“HARP”). In spring 2015 in NYC, all adult Medicaid recipients who are not dually enrolled in Medicare will start receiving mental health and addiction services through their chosen insurance plan. Members with greater behavioral health needs will be enrolled in a HARP, and will have a personal assessment to determine eligibility for recovery services.

Several challenges remain before the state can successfully implement HARPs and integrated managed care for over seven hundred thousand Medicaid beneficiaries who use behavioral health services. The greatest challenge is arranging effective care management for every HARP recipient.

Care management is the backbone of NYS’ plans for Medicaid redesign, and Health Homes were implemented statewide to meet the challenge of coordinating care for people with mental, substance, and physical health needs. The implementation of Health Home care management has met challenges since the beginning, including low reimbursement rates for care managers and high case loads. Many Health Home beneficiaries have needs that include homelessness, legal implications of criminal justice involvement, and complex health needs that make behavioral health problems harder to manage.

Care managers have worked hard and in some instances have offered successful coordination, but in others have not been able to effectively assist individuals with all of these needs.

The current expectation is that Health Home care managers will provide a detailed assessment for HARP beneficiaries that can translate into a plan of care that may include an integrated set of recovery services. The plan of care will have to be translated to the HARP insurance plan and then coordinated amongst a network of service providers.

Achieving this for all HARP recipients in a timely way will be very complicated, particularly because the Office of Mental Health (OMH) and the Office of Alcoholism and Substance Abuse Services (OASAS) are estimating eighty thousand NYC residents will be eligible for these assessments as soon as the plan is implemented. The complexities around care management must be negotiated between state agencies and HARP plans, in recognition of the barriers within Health Home implementation and the needs of Medicaid recipients.

NYAPRS has been advocating for the recovery-oriented services offered in a HARP—like peer supports, crisis diversion, family caregiver training, non-medical transportation, and supported employment and education—for years, recognizing their ability to keep people leading a full life in the community. The management of these services by insurance companies will be a new approach to behavioral health delivery.

Managed Care Organizations offering HARP services were evaluated with strict criteria from OMH, OASAS, and the Department of Health. They have to meet readiness standards and a feedback process to the state by which they will be evaluated. But they also have to provide access to a range of new services that have never been offered on such a large scale before, and understand social outcomes like employment and education.

The challenges around recovery services aren’t only at the level of the insurance company, but through interactions between provider and beneficiary. “Recovery-orientation” is easy enough to say, but entails far more than adding a new list of services to a program. Training on best practice models and continuous quality assurance in community behavioral health has previously been the responsibility of OMH and OASAS. They may take on this role to a greater degree in our transformed system, or may rely on HARPs to ensure quality service delivery.

In order to meet access needs, new rehabilitation services including crisis respite, supported education, and psychosocial rehab will be provided by some “traditional providers” like clinics. The ability for these providers to understand the nuances of a recovery journey, support that journey effectively, and offer real change to our community members is a future that seems far away from our current delivery system. The system as a whole must create expectations for standardization and quality improvement and then commit to meeting that challenge.

Many genuine and hard-working people who promote recovery are guiding this transformation within state agencies, community programs, and HARP insurance plans, but rising above the complexities and achieving the challenge of recovery-oriented service delivery will be reliant on dedicated partnerships. The protection of Medicaid beneficiary service access and rights throughout this process must be maintained, without allowing the possible pitfalls of change hinder true progress in our mental health and addiction services.