Technology, Waivers and Wraparound...SMO for behavioral health, substance use and CSoC. • Louisiana Medicaid executes five year 1915c waiver. 2008-2011 • Medicaid begins exploring

Technology, Waivers and Wraparound: How to Build a Successful CSoC Program within a Medicaid Framework and an Evolving Healthcare Market

Wendy Bowlin, MS, LPC, MBADirector of Quality and Outcomes, Louisiana CSoCMagellan Health

Magellan Health: One company, two unique platforms

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Objectives

Evaluatestrategies for an effective statewide implementation of a Coordinated System of Care based on a Wraparound Model.

Magellan in Louisiana CSoC 3

Discuss the utilization of Child and Adolescent Strengths and Needs (CANS) assessment to meet waiver requirements and monitor outcomes.

Identify factors that enhance sustainability of a Medicaid wraparound program through ever-changing healthcare system.

Strategize how to build a resilient Coordinated System of Care program to meet the many challenges.

CSoC: The Louisiana Model

Louisiana’s Coordinated System of Care

At inception, the goals of the CSoC included:• Reducing state’s costs by leveraging Medicaid and other funding sources as well as increasing service

effectiveness and reducing duplication across agencies

• Reducing out-of-home placement for children currently in placement and future admissions of children and youth with significant behavioral health challenges and co-occurring disorders

• Improving the overall outcomes of children and their caregivers


The Louisiana Coordinated System of Care (CSoC) began March 1, 2012.

Serves children and youth ages 5 - 20 who have serious mental health and substance use challenges and are in or at risk of out-of-home placement.

Offers wraparound facilitation and CSoCwaiver services and supports that help these youth return to or remain at home while they are being helped.

The Evolution of CSoC

5 Magellan in Louisiana CSoC

2015-Current

• LA shifts to an integrated, carved-in model for behavioral health.

• CSoC: carved-out specialty children’s program under Magellan’s management.

• CMS renews 1915c waiver for 5 years. Amendments include max enrollment capacity increased to 4600 and age range changed from 0-21 to 5-20.

2012-2015

• Implement CSoCsimultaneously with the execution of state’s first-ever Medicaid managed care model, a carved-out behavioral health model.

• Magellan serves as the SMO for behavioral health, substance use and CSoC.

• Louisiana Medicaid executes five year 1915c waiver.

2008-2011

• Medicaid begins exploring a 1915c waiver for HCBS services.

• CSoC structure developed based on wraparound principles.

• Establish a 1915b3 waiver for lower levels of need.

Benefits of CSoC

Along with access to traditional Medicaid behavioral health and substance use services through the 1915b waiver, enrollees in CSoC also receive:


Independent comprehensive assessment to guide planning

Connection to Wraparound Agency (WAA)

Connection and to Family Support Organization (FSO)

Individualized care planning process through Child and Family Teams (CFTs) to link families to services/supports

Access to specialized services• Parent Support and Training• Youth Support and Training• Short-Term Respite• Independent Living/Skills Building

CANS and Waiver Compliance

How CANS Drives the CSoC Engine


Outcomes

ProcessCANS

Algorithms

Waiver Requirements

Performance Measures

Louisiana CSoC Waivers:CANS from Screening to Eligibility


Risk Screen

Brief CANS Screen

Full CANS

1 2 3

• Member Support Risk Screening

• Yes to any risk question

• Completed by MCOs

• All Care Managers are CANS certified

• Algorithm

• Completed by CSoC contractor

• Independent Assessor* (LMHP)

• Algorithm

• Completed by external provider and validated by CSoC contractor

Meeting Waiver Requirements

Level of need (CANS/IBHA) is required to be completed at least once every 6 months for eligibility purposes.

• Completed by an Independent Assessor

• Contractor maintains an internal independent reviewer for quality assurance processes

• Level of care determination governs 1915c or b3 eligibility assignments


Alignsperformance measures with waiver requirements.

• Ensures Plan of Care addresses all actionable needs (items scored as 2 or 3)

• Reporting on performance measures established to monitor clinical and school improvements

• Used to validate Wraparound Facilitator self-report data

Moving to an Integrated Medical Model

Challenges


Financial Eligibility and Integration

Establishment of presumptive eligibility period via the 1915b3 waiver to verify fiscal and clinical eligibility, allowing CSoC members to transition seamlessly from an at-risk MCO plan to an ASO CSoCcontract.• Most children meet full eligibility due to a comprehensive brief CANS assessment

and parental financial disregard allowance.

Magellan always responsible for CSoC waiver specialty services and Wraparound Facilitation.

MCOs always responsible for residential services (e.g., Psychiatric Residential Treatment Facility, Therapeutic Group Home, Residential Substance Use, etc.), which are services that are non-compliant with CMS’s Home and Community-Based Setting Rule

Inpatient and outpatient behavioral health and substance use services are managed by the CSoC contractor as defined by established payment protocol.

Challenges


Referral Process and Integration

The model requires single point of entry through MCOs; however, CSoC contractor can accept referrals.

This ensures coordination of care between MCO and WAA regarding current services.

Risk questions completed by MCOs.• If answers “yes” to any risk question, there is a warm

transfer to CSoC contractor to conduct Brief CANS.

WAAs still play central role in assisting members to navigate through the referral process.

Challenges


Family Support Organization

FSO responsible for providing youth and parent support and training services (2 of the 4 specialized CSoC Services)

Multiple models have been implemented through a RFI selection process:• One FSO per region (2012-2013)

• Statewide family-run organization serving all regions (2013-2017)

• Largest service expenditure due to scope and scale of organization

• Option for multiple organizations that meet specific business, staffing and training requirements

• Removed family-run organization requirement but placed strong emphasis on training of peers in RFI selection process.

Enhancing System Capabilities

Technology Infrastructure

MagellanProvider.com platform was modified to allow multiple providers to submit CANS electronically.• Allows for seamless data collection and enhanced data analysis.

• Provides mechanism for data exportation to support WAA EHRs.

• Reporting capabilities to support better member management.

Magellan implemented quarterly scorecards to track key indicators and performance measures.


Understanding Regional Differences

0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0% Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

Region 8

Region 9


Magellan uses CANS data

to better understand regional population

differences that could affect member needs.

Evaluating Individual Program Characteristics


Statistical analysis using Cramer’s V was conducted to see if certain factors, such as peer involvement or involvement with Juvenile Justice, had an association with the level of CANS change scores.

• The enriched and complex dynamics of wraparound and CSoC made it difficult to isolate individual program characteristics impacting overall outcomes through this type of analysis.

• It was successful in validating Wraparound Facilitator self reported outcomes regarding members’ overall success in program.

Take away: CANS is a good tool to evaluate overall program outcomes but further research is needed to understand if it is the best tool to evaluate isolated program characteristics. Moving towards use of CANS to support decision-making models and predictive analytics.

Sustaining Program through Achievement of Goals

Reduction in High Cost of Inpatient Care

0.0%

0.5%

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Perc

ent

Month and Year

SMO CSoC


Strong Outcomes Year-over-Year


Initial Discharge

All Youth 2015 56 43.1

All Youth 2016 57.8 41.5

All Youth 2017 58.6 41.6

30

35

40

45

50

55

60

65

CANS Global Scores

Meeting Members Needs


0%

2%

4%

6%

8%

10%

12%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Perc

ent

of

Enro

llmen

ts

Init # Actionable Needs Interquartile

0%

5%

10%

15%

20%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38

Perc

ent

of

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llmen

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DC # Actionable Needs Interquartile

There were 9 less actionable needs from

Initial to Discharge CANS.

Init

ial (

n=5

63

7)

Dis

char

ge (

n=3

04

7)

Less complex More complexRed box accounts for ~50% of youth.

Median: 15 Actionable Needs

Median: 6 Actionable Needs

Actionable Needs: Score of a 2 or 3

Understanding the Change


Breakdown of the net decline of the median 7 actionable needs from initial to discharge (medians): 9 met actionable needs, 4 stayed actionable needs, 40 non-actionable needs, and 1 actionable need gained.

0%

2%

4%

6%

8%

10%

12%

-37 -35 -33 -31 -29 -27 -25 -23 -21 -19 -17 -15 -13 -11 -9 -7 -5 -3 -1 1 3 5 7 9 11 13 15 17

Perc

ent

of

Enro

llmen

ts

# Net Actionable Needs from Init to DC Interquartile

0%

2%

4%

6%

8%

10%

12%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

Per

cen

t o

f En

rollm

ents

# Met Actionable Needs from Init to DC Interquartile

Median of 9 met actionable needs.

Median net loss of 7 actionable needs.

Red box accounts for ~50% of youth.

Most Frequently Identified Needs


83.7% 83.7% 83.5% 81.6% 80.6%

42.7% 41.6%46.2%

35.7%43.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Fcn - Fam Fcn - Soc CBE - Imp CBE - Ang Fcn - Judg

Actionable Needs Prevalances

Initial Discharge

Externalizing behaviors and problems with relationships are the most commonly identified needs. • CSoC is achieving reductions of at least 55% in percent of children with

these actionable needs at discharge.

Resolving High-risk Needs


*Needs that were identified by ˂20 of LA youth at enrollment have been excluded from this analysis.

90.3%

89.1%

85.4%

84.0%

83.9%

83.6%

83.6%

82.7%

81.8%

77.4%

70.0% 75.0% 80.0% 85.0% 90.0% 95.0%

CG - Dev

Risk - Fire

CG - Safe

Risk - Sui

CBE - BehReg

Acc - ID

Risk - SelfMut

Risk - SexAgg

CBE - Eat

Risk - SelfHarm

High-risk needs include behaviors that would likely lead to future out-of-home placements.• 5 of the top 10 most commonly met needs at discharge are child risk needs. • 8 of the 11 child risk needs are included in the top 20.

Advancing System Growth

Recommended Next Steps


• Provide monthly CANS reports to assist supervisors in identifying youth showing lack of progression

• Increase education on reporting functions of MP.com to enhance individual member management

• Inform selection of members for clinical rounds between WAA and Magellan

• Enhance monitoring of high LOS youth (i.e., required to be assessed once every 3 months)

• Identify regional population differences to inform network and resource development activities for specialty needs and foster-specific stakeholder relationships

• Utilize data to identify continued areas of educational and training needs for providers and WAAs

Improve Relationship with Wraparound Agencies –

Strengthening Partnership

+

Use CANS outcomes to continue program growth and better

understand member differences

Confidentiality statement for educational presentations


By receipt of this presentation, each recipient agrees that the information contained herein will be kept confidential and that the information will not be photocopied, reproduced, or distributed to or disclosed to others at any time without the prior written consent of Magellan Health, Inc.

The information contained in this presentation is intended for educational purposes only and is not intended to define a standard of care or exclusive course of treatment, nor be a substitute for treatment.

Documents

Technology, Waivers and Wraparound...SMO for behavioral health, substance use and CSoC. • Louisiana Medicaid executes five year 1915c waiver. 2008-2011 • Medicaid begins exploring