Over the last several years, the community behavioral health landscape has changed. New York State is driving reforms toward achieving the Triple Aim for better care and improved health at lower costs. In doing so, the community-based behavioral health sector has been charged with undergoing several system transformations: moving from fee-for-service to managed care, integrating behavioral health care with physical health care, participating in initiatives like the Delivery System Reform Incentive Payment (DSRIP) program and transitioning to Value Based Payment (VBP) arrangements.
All the reform puzzle pieces offer community-based providers opportunities for advancing whole health outcomes among individuals living with severe mental illness and substance use disorders. While maneuvering through the labyrinth of system transformation, community-based providers have changed people’s lives for good through providing stable housing, employment, education and care management services. At the same time, providers struggle with aligning policy with practice.
Care Integration
Integrating care is a desirable goal to ease the fragmentation of physical and behavioral health services. There is no one straight path to integration. In fact, there are several and they can be bumpy an uneven. Total integration with a full-service team that is holistic, interdisciplinary and person-centered is exemplified by the federally Certified Community Behavioral Health Clinic (CCBHC) program. CCBHC’s provide a comprehensive range of addiction and mental health services, while meeting additional requirements related to staffing, governance, data and quality reporting and more. In return, CCBHC’s receive a Medicaid reimbursement rate based on their anticipated costs of expanding services to meet the needs of these complex populations.
Other examples of integration include, collocating with another group of licensed specialists; sharing office space where providers share regulatory accountability and inform consumers of who is providing their services; or referral with a “hot handoff” to other behavioral health or physical health services. Additionally, there is the practice of lean integration, which involves continuously improving data and systems flow, patient flow, prevention, removing access barriers, while keeping back office functions as is; as well as employing peer navigators and health outreach workers. However, meeting regulatory obstacles is complex and expensive. It can involve significant capital investments such as the acquisition of new sites, expanding or retrofitting existing space and purchasing new equipment. It can require obtaining new health information technology (HIT) platforms, electronic health records (EHR) and telehealth capabilities. In addition, there is the implementation and coordination of new billing processes, linking with the health information exchange (HIE), adding workforce capacity, coordinating care across multiple entities, training for staff on oversight and data analytics, and gauging ambiguous criteria for care transitions.
Care Collaboration
Surviving and thriving in the current environment requires being part of a collective, effectively working together, utilizing shared resources and infrastructure to meet provider missions more efficiently. System transformation created several networking opportunities to nurture a more integrated system of care, embracing Managed Care Organizations (MCOs), Performing Provider Systems (PPSs), Accountable Care Organizations (ACOs), Independent Practice Associations (IPAs), Behavioral Health Care Collaboratives (BHCCs), Health Homes, and other care delivery entities.
The move to Medicaid managed care brought about Health and Recovery Plans (HARPs), which are specialty health plans for people living with severe mental illness and substance use disorders. HARPs are crucial for VBP contracting and quality management to happen, as well as access to Home and Community Based Services (HCBS) to help individuals achieve life goals and be more involved in the community. While HCBS providers prepared for and invested in high volume HCBS infrastructure, the quantity envisioned has not come to fruition, and HCBS remains misaligned with the realities on-the-ground.
Participation in DSRIP and the PPSs was intended to be an important step forward towards achieving the goal of integration. Community-based providers have devoted a lot of time and resources into DSRIP, but for them the hope has not been realized. The hospital-based PPSs have largely held on to DSRIP funding and the program is scheduled to conclude in 2020, with many PPSs transforming into ACOs or IPAs.
Health Homes are designed to be the lynchpin of integration, providing care coordination that links behavioral health with primary care, addresses social determinants of health and avoidable use of hospitals. Yet Health Homes are not without their own engagement challenges and bureaucratic obstacles. For most enrollees, Health Home payments and care management functions are flowing through MCOs. As the program continues to evolve, Health Home leads and Care Management Agencies (CMAs) are looking to change their business models and engage in strategic partnerships to enlarge their network for referrals.
Value-based payments adds another critical dimension that will shape the system and the future. As a result, providers are now forming specialized networks to deliver care through ACOs, IPAs and BHCCs. To help behavioral health providers prepare for Value Based Payment arrangements, the NYS Behavioral Health Value Based Payment Readiness Program was launched with $60 million over three-years to fund selected BHCCs. The BHCCs are tasked with enhancing the collective quality of care by facilitating a shared infrastructure that is clinically and financially integration with the use of community-based recovery supports, and utilization of service data to improve behavioral and physical health outcomes. Under the vision of value-based payments, plans will delegate some risk, network development and care management activities. But for VBP network contractors to be successful, access to real-time and actionable health plan and PPS data is fundamental, in addition to the capability to meaningfully partner with MCOs, and having opportunities to reinvest shared savings back into the collaborative.
Care Outcomes
As the demand for mental health and substance use services increases, New York State (through its mid-level payers and community providers), is obliged to provide optimal care to the most vulnerable and complex populations. Nonprofit mental health and substance use providers are dedicated partners with the state in holding up the safety-net up and keeping it intact. They go above and beyond their initial missions to ensure that services in the community are available to all who need them, despite fragmentation and persistent disparities and gaps in care throughout the service delivery system.
For the Triple Aim to succeed, community-based providers must have the resources that are necessary to deliver high-quality, integrated, collaborative care. This includes investing in a high-quality, specialized workforce that is committed to achieving these ambitious goals. Furthermore, system transformation requires a thoughtful change management strategy. As it evolves, evaluation and assessment of the strategy need to occur with necessary modifications along the way.
Positive consumer outcomes are at the center of the continuum of care provided by community-based behavioral health providers. This entails social supports and preventative care through the entire life-cycle to increase independence and better health outcomes for people living with mental illness, who die on average of 25 years younger than the general population. In addition, ending the stigma surrounding behavioral health so that people are comfortable seeking help before a crisis arises.
It is therefore necessary to ensure the sustainability and viability of the sector to guarantee that consumers have access to and receive the high quality, integrated care that they deserve as articulated under the goals of the Triple Aim: better care and improved health at lower costs.
