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.

Medicaid Managed Care: Recovery Moves to the Mainstream

Medicaid Managed Care: Recovery Moves to the Mainstream

By Briana Gilmore, Director of Public Policy and Advocacy, New York Association of Psychiatric Rehabilitation Services (NYAPRS)

Learn More About the Trends That Will Affect You

Big changes are coming soon to New York’s Medicaid system. Services are being overhauled to emphasize quality and outcomes, and new services are being added to ensure that Medicaid is paying for the most cost-effective and valued treatment. Why is this good news? These changes will be beneficial to all Medicaid consumers who use behavioral health (BH) services. In fact, New York will implement changes in 2015 that emphasize recovery-oriented BH services in unprecedented ways.

This change started in 2011 when Governor Cuomo instituted the Medicaid Redesign Team, a planning system that looked at outcomes of the Medicaid system and made targeted changes. The goal was to build off reforms central to the Affordable Care Act, with the mission of reducing overall cost while improving outcomes and quality care. Policy makers quickly realized that achieving this would be particularly challenging for the BH system.

New York is transitioning the BH system because recovery-focused services not only improve quality and outcomes, but also save money. This plan also raises the bar for providers, many of whom have long been funded based on how often people come to programs rather than demonstrated improvements in people’s lives. In order to achieve this transition, the plan targets social determinants of well-being such as housing, employment, education, and family connections.

DOH, OMH, and OASAS have decided to accomplish this by moving to a system of managed care that will be expected to improve the coordination and impact of care.

Managed care isn’t new, and many who are Medicaid eligible already have physical health and pharmacy services paid for by a Managed Care Organization (MCO). In 2015, every person in New York State who is eligible for Medicaid will also have their mental health and addiction services coordinated and paid for by an MCO.

If you are already enrolled in an MCO, you will receive all of your benefits from the same plan. If you’re not enrolled, you will have to choose an MCO. If you’re not sure about which plan to choose or if you want to switch, you can access an enrollment broker to help you do so.

Medicaid recipients who have used a lot of mental health and addiction in the past will be enrolled in a Health and Recovery Plan (HARP) that will offer and coordinate a greater amount of those services.

Thanks to advocacy from NYAPRS (New York Association of Psychiatric Rehabilitation Services) and other advocacy groups, HARPs are required to offer services that have never been Medicaid funded, including peer services, crisis respite, supported employment and education, family supports, non-medical transportation, and self-directed care.

Some of these services, like crisis respite, will be available as needed. But others will be offered based on goals you express during treatment planning with a care manager, such as transitional employment. This will be a major change for many people; instead of just being offered service options, people in HARPs will be asked what their recovery goals are and what supports they need to get there. It will take time to build a system that understands how to do this, but it will also take time before all community members are able to articulate what their goals and preferences are.

Ideally, that is what care management is all about. Health Homes are established throughout the state to provide care management that excels at helping people access services they really want and need, including community supports like housing and wellness activities. Health Homes are just networks of providers organized by a central agency; they aren’t a place, but have care managers that provide outreach in community settings.

Health Homes are operating with mixed success. Their capabilities depend on the strength of their provider network and ability of staff to truly understand the needs of our community, including cultural norms and preferences. Care Management will be a big part of the way MCOs understand and organize services in the future, particularly through HARPs. MCOs will have to work with Health Homes to ensure each recipient receives the attention that helps them achieve the best life possible in the community.

This historic shift in the way Medicaid is delivered will mean dramatic improvements in the way the community accesses services that truly help people recover. But it won’t happen perfectly all at once, and recipients may have to press for better attention from care managers, more appropriate service access, or demand community-based living and service options. NYAPRS and Medicaid Matters New York, along with other associations, achieved the inclusion of an ombuds program in Medicaid Managed Care; an ombuds is an office that can objectively help resolve complaints and help consumers navigate problems.

Importantly, this shift is just one of many moving toward a more coordinated system. People who need nursing home or long-term care services will also experience changes in services coordination, and eventually everyone in New York State who has Medicare coverage will elect an MCO. Stay updated through community forums for information about how benefits you receive are improving and what you can do to advocate for what you and your peers need.