By Sheryl Allenson, J.D.
CMS issued a letter to state Medicaid directors announcing opportunities to design service delivery systems for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED) who are receiving medical assistance under the 21st Century Cures Act, (Cures Act). The letter outlined two areas, including (1) "strategies under existing authorities to support innovative service delivery systems," and (2) "SMI/SED demonstration opportunity" (CMS Letter, SMD #18-011, November 13, 2018).
As to the first area, CMS explains that earlier identification of SMI/SED is necessary, with focus on earlier treatment. This includes support for the development of referral networks to mental health providers and screening for mental health conditions, with improved access to mental health treatment in a school setting. CMS noted the importance of earlier treatment in light of research findings showing that adolescents and young adults with psychosis have a much higher risk of death in the first year after diagnosis.
SMI and SED are often identified outside of a mental health setting as requiring treatment. If these settings are connected, local mental health providers can help improve access to early treatment and services. CMS highlights the importance of communication between the entities and noted that it is imperative that availability be widened of behavioral health screenings and mental health and substance abuse disorder services in schools. The letter explained that these services could be made more available under the early and periodic screening, diagnostic, and treatment (EPSTD) benefit, and discussed what the EPSTD benefit provides.
Significantly, CMS discussed the integration of mental health care into primary care. This integration is designed to promote earlier identification of SMI and SED, so that treatment could commence sooner. One evidence-based model for doing this is the Collaborative Care Model. Here, a team approach is employed, where the primary care doctors (PCP) treat mental health and substance abuse disorders (SUD), and the PCP’s are supported by a behavioral health care manager and a psychiatric consultant. The letter lays out in detail the key components of the Collaborative Care Model. Another model highlighted is the Child Psychiatry Access Model.
There are impediments to the broader implementation of these models, according to CMS. For example, there is a lack of reimbursement for consultation and care coordination that occurs outside of the patients’ presence. On the other hand, CMS explained that there is a manner in which reimbursement might be feasible.
CMS also discussed "improved access to services across the continuum of care, including crisis stabilization services." This highlights the need for treatment on a continuum, specifically intermediate levels of care outside the need for impatient treatment and outpatient care for less serious conditions and on-going maintenance therapy. CMS states that there are strategies to ensure people with SMI or SED receive appropriate levels of care. Specifically, evidence-based assessment tools that link clinical assessment with level of care should be used. Another of several strategies discussed by CMS is increasing the availability of intense outpatient and crisis stabilization programs. CMS also laid out the importance of and plans for better care coordination and transitions to community-based care."
In addition to considering these strategies, CMS discussed SMI/SED demonstration opportunities. This would allow states to receive federal financial participation (FFP) for services provided to Medicaid beneficiaries for certain services provided at institutions for mental disease (IMD) if the states "are also taking action, through these demonstrations, to ensure good quality of care as IMDs and to improve access to community-based services." Demonstration opportunities for SMI/SED and SUD may go on contemporaneously. The CMS letter explains that demonstration projects will not be approved unless the project is expected to be budget neutral to the federal government. Moreover, states participating in the demonstration projects will also be expected to make a commitment to take "a number of actions to improve community-based health care."
The letter spells out CMS’ specific goals for the demonstration projects, as well as milestones. Goals include (1) the reduced utilization and length of stay in emergency departments by Medicaid beneficiaries with SMI or SED while waiting for treatment for these conditions, (2) "reduced preventable readmissions to acute care hospitals and residential settings, (3) improved availability of crisis stabilization services, (4) improved access to community-based services to handle chronic mental health needs of Medicaid beneficiaries with SMI or SED, and (5) improved care coordination, including continuity of care in the community after episodes of acute care in a hospital or residential setting.
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