This large group meeting is hosted by the National TA Network for - - PowerPoint PPT Presentation

This large group meeting is hosted by the National TA Network for Children’s Behavioral Health (TA Network), operated by and coordinated through the University of Maryland.

This presentation was prepared by the National Technical Assistance Network for Children’s Behavioral Health under contract with the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Contract #HHSS280201500007C. Disclaimer: The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services (CMHS), the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services (HHS).

APPROACHES TO ADDRESSING BEHAVIORAL HEALTH DISPARITIES IN MEDICAID MANAGED CARE SYSTEMS

Selena Webster-Bass Alaska Nebraska

Learning Goals

Describe behavioral health disparities, root causes and the impact of social determinants Identify approaches to addressing health disparities using the National Culturally and Linguistically Appropriate Services (CLAS) Standards Discuss community examples of culturally responsive engagement and

• utreach, use of

data and intervention strategies.

The Changing Face of America

Behavioral Health Disparities

• Behavioral health disparities continue to exist in the United

States across various sub-populations including disadvantaged communities, racial and ethnic groups, LGBTQ+ communities, youth with disabilities and transition age youth.

• Compared with the majority population, racially and

ethnically diverse groups are:

– Less likely to receive quality care.1 – More likely to use hospitals and inpatient facilities for mental health services rather than community-based services;8 and – Less likely to receive mental health care when needed; 11

Contributing Factors to Behavioral Health Inequities

• Several factors at the individual, provider, community and

systems levels contribute to behavioral health inequities.

• Social Determinants
• Cultural values
• Social stigma
• Reliance on faith, family and friends for mental health support
• Lack of access and utilization of behavioral health services
• Structural Inequities
• Trauma (Historical, Adverse Childhood Experiences etc.)
• Agencies’ lack of organizational-level considerations in honoring and

addressing the cultural needs of diverse populations

• Implicit and explicit bias of providers
• Shortage of behavioral health providers
• Lack of racially and ethnically diverse providers

Equity

Center for Story-based Strategy and the Interaction Institute for Social Change in April 2016. The artist is Angus

• McGuire. https://www.storybasedstrategy.org/the4box.html2

Addressing Behavioral Health Inequities

Examples of Approaches to Addressing Behavioral Health Inequities2

• Application of the National Culturally and Linguistically Appropriate Services (CLAS)

Standards

• Use of culturally adapted interventions that use care managers to increase engagement

among individuals with Limited English Proficiency (LEP) and limited health literacy

• Decrease systems fragmentation by establishing integrative care models that use care

managers to link families to primary care, mental health services, social supports and preventive care

• Use of technology for appointment reminders, self-management, community education,

telemedicine and stigma reduction

• Establish broad data standards for behavioral health and social determinants to improve

health disparities tracking

• Clinical interventions that promote the early identification of mental illness symptoms and

removal of financial barriers

• Build a diverse and culturally responsive workforce

Source: Closing the Gaps: Scaling up to reduce mental health disparities in the United States (2013) https://www.nimh.nih.gov/research-priorities/scientific-meetings/2013/closing-the-gaps- scaling-up-to-reduce-mental-health-disparities-in-the-united-states.shtml2

National Culturally and Linguistically Appropriate Services (CLAS) Standards

Advance Health Equity Improve Quality Eliminate Health Disparities

National CLAS Standards Themes

Governance, Leadership and Workforce Development Communication and Language Assistance Continuous Quality Improvement and Accountability

Culturally and Linguistically Appropriate Practices

CLAS and Medicaid Integration

Domains Examples Governance, Leadership and Workforce Development

• Establishing cultural and linguistic competency committees
• Inclusion of racially and ethnically diverse providers and

traditional providers

• Cultural and linguistic competency Training for Providers
• Use of plan surpluses

Communications and Language Access

• Complete access to interpreter services
• Partnering with community organizations for interpreter

trainings, interpreter pools and provider trainings

• Translation of managed care plan materials

Continuous Quality Improvement & Accountability

• Clear definition of populations and service areas for which

health services are required

• Use of Community Health Workers Program
• Community participation in plan services development

CLAS and Medicaid Integration

Governance, Leadership and Workforce Development

• Assess organizational readiness for change
• Conduct organizational assessments with document reviews
• Develop a Cultural and Linguistic Competency (CLC) Plan
• Embrace 2-D diversity (Inherent and Acquired) of
• rganizational leaders and staff
• Establish cultural and linguistic competency training policies
• Conduct a training assessment and develop training plans
• Implement, monitor and evaluate trainings
• Include peer support as a reimbursable service within

managed care organizations

CLC Plan

CLAS and Medicaid Integration (cont.)

Communication and Language Access

• Issue interpreter services guidelines

– Certification Exams – Capitation rates for multilingual services

• Establish guidelines for provider proficiency
• Simplify the process for producing and approving translated plan materials

CLAS and Medicaid Integration (cont.)

Continuous Quality Improvement and Accountability

• Data systems capable of tracking and providing information about care

delivery, differentiated by population characteristics – Assess the validity of demographic databases used by managed care plans and departments – Assess the utility of information gathered during initial assessments – Link cultural demographic factors to utilization patterns and process measures – Collect and analyze Consumer Assessment of Health Plans Survey (CAHPS) data to gain insight into youth/family satisfaction and engagement with services – National accreditation programs for managed care providers should include a cultural competence component by which differences in process and outcomes measures by racial/ethnic or linguistic group can be examined.

Use of Cultural Competence Data

Jacksonville System of Care: Collaborative Care Model

JSOC: Collaborative Care Model

• Interdisciplinary team of primary care and behavioral health professionals
• Increasing access to health care coverage through use of Care Coordinator/Utilization

Specialist

• Language access

– Contracts for interpreter and translation services

• Cultural assessments with youth and families

– Race/Ethnicity – Socioeconomic Status – Sexual Orientation, Gender Identity and Expression (SOGIE) – Faith/Spirituality – Geographical – Resident status

• Referrals to multicultural resources
• Cultural data tracking, collection, monitoring and evaluation
• Tracking suicidal and homicidal attempts/crisis stabilization unit (CSU) recidivism, 7-day

follow-up appointments post discharge from CSUs, care coordination follow-up to ensure psychiatric and therapy appointments within 30 days

Participating States and Counties

 Alaska  Nebraska

MEETING THE BEHAVIORAL HEALTH NEEDS OF ALASKAN NATIVES IN REMOTE COMMUNITIES

Terry Hamm DBH – Medicaid Provider Assistance Services

Alaskan Behavioral Health Aide Program

Behavioral Health Aides (BHA)

https://vimeo.com/97368656

Alaska Tribal Health System

• Alaska is “remote” not “rural.”
• The majority of Alaskan communities are only

accessible by air or ferry.

• Alaska is divided in Tribal Health Regions
• Each region has a “hub” community. Hub

communities:

– Are the largest community in the region and house all services for the surrounding villages – Most hub communities have either a hospital or large primary care clinic

Alaska Tribal Health System

BHA History

• To meet the behavioral health needs in Alaska’s

remote communities of the Alaska Native Tribal Health System, a para-professional class of behavioral providers was developed.

• Behavioral Health Aides follow in the foot steps of

the Community Health Aides, that have provided basic medical care for over 30 years.

BHA Levels

• The Alaska Native Tribal Health Consortium developed

a rigorous Certification process for four levels of BHAs:

– BHA I – Focus of a BHA I is prevention. BHA I may also provide low level rehabilitative services. – BHA II – A BHA II has training to diagnose and treat Substance Use Disorders for youth and adults . – BHA III – A BHA III is trained in Mental Health services and can diagnose and treat both Mental Health and Substance

• Use. BHA III also act as “leads” to BHA I and BHA II.

– BHA/Practitioner – A BHA/Practitioner can supervise all BHA Levels and provide full Substance Use and Mental Health treatment.

BHA Certification Process

• BHAs have several avenues to obtain the appropriate credit courses

for certification: – Trainings directly through Alaska Native Tribal Health consortium (ANTHC) – Rural Human Services program through the University of Alaska Fairbanks – Alaska Regional Alcohol and Drug Abuse Counselor Training (RADACT) that provides Chemical Dependency Counselor certification

• Each BHA level must also have a specified number of clinical

supervised hours by a licensed mental health clinician.

BHAs and Medicaid

• The majority of the Tribal Behavioral Health programs are enrolled

in Medicaid as Community Behavioral Health (CBH)Centers

• Within the Behavioral Health Medicaid regulations the state

recognizes a “Clinical Associate – Less than a Master’s Degree” as a valid rendering provider for Rehabilitative Services for: – Children with Severe Emotional Disturbance – Adults with Severe Mental Illness – Children and Adults with co-occurring Substance Use / Mental Illness

• BHAs are considered Clinical Associates under a CBH center and

Medicaid renderers

Reimbursement for BHA Services

• In 2007 the State and the Tribal Health system

entered into negotiations to amend the Alaska State Plan to do the following: – Recognize Tribal CBH centers as “clinics” and eligible for the Federal Tribal Medicaid Encounter rate – The current reimbursement rate is $616/day

Increasing BHA Services and Rates

• In May 2016 the State of Alaska and the Tribal Health Center

again entered into negotiations to further increase the Medicaid capacity of BHAs and in turn increase Behavioral Health services in Alaska’s villages.

• To meet this goal the following was agreed to:

– The Medicaid State Plan was amended to add BHAs as independent Medicaid renderers, separate from Community Behavioral Health

Rationale for 2016 BHA SPA

• During the May 2016 Tribal/State negotiation, the tribes brought for the

following concerns: – The current CBH system was very cumbersome and requires individuals and families to reach a crisis point before qualifying for services – The BHA certification process more than prepares BHAs to provide low-level Behavioral Health Interventions that could prevent the need for crisis intervention – The ultimate goal of the tribal system is to have families receive care sooner than later and in turn decrease the number of children taken into custody or sent to out-of-state care

New Initiatives

• ANTHC is currently working with Alaska Pacific University to
• ffer credit hours towards a BSW for each level of BHA

Certification.

• The hope is more BHAs will move on to BSW and MSW

education levels.

• Certification Standards and Training Matrix
• http://www.akchap.org/html/chapcb/bha---certification-

board-documents.html

Questions/Discussion

• Describe cultural and linguistic competency efforts

in your community specific to the CLAS Standards.

• What have been your successes?
• What have your challenges?

Contact Information

Selena Webster-Bass Voices Institute, LLC selena@voicesinst.org Terry Hamm DBH – Medicaid Provider Assistance Services Terry.hamm@alaska.gov

Resources

University of South Florida – Cultural and Linguistic Competency Library http://cfs.cbcs.usf.edu/projects-research/detail.cfm?id=488 Nationally Culturally and Linguistically Appropriate Services (CLAS) Standards https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedNationa lCLASStandards.pdf

References

• 1. Alegría, M., Chatterji, P., Wells, K., Cao, Z., Chen, C., Takeuchi, D., et al. (2008). Disparity

in depression treatment among racial and ethnic minority populations in the United

• States. Psychiatric Services, 59(11), 1264-1272.
• 2. Center for Story-based Strategy and the Interaction Institute for Social Change in April
• 2016. The artist is Angus McGuire. https://www.storybasedstrategy.org/the4box.html
• 3. Closing the Gaps: Scaling up to reduce mental health disparities in the United States

(2013) https://www.nimh.nih.gov/research-priorities/scientific-meetings/2013/closing- the-gaps-scaling-up-to-reduce-mental-health-disparities-in-the-united-states.shtml

• 4. Marrast, L. Himmelstein, D. and Woolhander, S. (2016). Racial and Ethnic Disparities in

Mental Health Care for Children and Young Adults: A National Study.

• 5. Pew Research Center Report, (2015) “Modern Immigration Wave Brings 59 Million to US

Driving Population Growth and Change.”

• 6. Pires, SA, Gilmer, T, Allen, K., McClean, J. 2017. Faces of Medicaid: Examining

Children’s Behavioral Health Service Utilization and Expenditures Over Time, 2005-2011. (In process). Center for Health Care Strategies: Hamilton, NJ

References

• 7. SAMHSA (2012) Mental health, U.S. 2010 (H.H.S. Publication No. [SMA] 12-4681).
• 8. Samnaliev, M. & McGovern, M. P. & Clark, R. E.(2009). Racial/Ethnic Disparities in

Mental Health Treatment in Six Medicaid Programs. Journal of Health Care for the Poor and Underserved, 20(1), 165-176. The Johns Hopkins University Press.

• 9. Schroeder, S.A. (2007). We Can Do Better – Improving the Health of the American

People, New England Journal of Medicine 357:122, 1 – 8.

• 10. United States Census Bureau (2011) Overview of Race and Hispanic Origin 2010.

https://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf

• 11. Wang, P. B., P.; Olfson, M.; Pincus, H. A.; Wells, K. B.; Kessler, R. C. (2005). Failure

and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62(6), 603-

• 613. 8.