The State of Arizona has seen promising results from its Medicaid “Targeted Investments” program designed to support integrating behavioral and physical health services. Now it is seeking a five-year extension of its Medicaid waiver from the Centers for Medicare & Medicaid Services to launch “Targeted Investments 2.0,” which would extend the concept of integrated care to include connecting individuals to critical social services when social risk factors are present.
On Nov. 18 the Center for Health Care Strategies, a nonprofit policy design and implementation organization devoted to improving outcomes for people enrolled in Medicaid, put on a webinar that featured Arizona’s approach to integrating behavioral health and primary care services.
Jami Snyder, the state’s Medicaid director, said thatfor several yearsArizona has been focused on behavioral health integration at three levels: at the state policy level, at the health plan level, and at the provider level.
Arizona had been working on integration with its long-term care program and its services for children over the last 10 years. “In 2018, we took the most dramatic step in our payer integration effort, when we integrated children and adults accessing general mental health and substance use services, so 1.5 million of our 1.8 million enrollees at the time transitioned into a fully integrated health plan product,” she said.
In 2017, in an effort to integrate care at the provider level, the state initiated its “Targeted Investments” program under the CMS 1115 waiver program. It was a $300 million program over a five-year period, and Arizona is now actually in the sixth year under an extension to the waiver. “We offer incentive payments to providers who've decided to join us in our integration journey,” Snyder explained. “It includes primary care practices, behavioral health organizations, acute psychiatric hospitals, and justice clinic sites. The real basis of the program is establishing a set of milestones that we offer incentive funding for.” Currently, 440 provider locations are participating in the program. The goals include reducing fragmentation, increasing efficiencies in the delivery system, and improving health outcomes for members.
Some of the milestones the state offers incentive funding for include the implementation of an integrated care plan, and participation in the health information exchange. (Snyder noted that two-thirds of Arizona providers receiving ADT alerts participate in the Targeted Investments program). Other milestones included the use of trauma-informed care protocols, making sure that peer and family support is available, in particular for justice-involved individuals under the justice clinic construct, screening for social determinants of health, making sure that in the primary care setting providers are screening for behavioral health needs, and ensuring that there are proper communication protocols that allow for integrated care at the point of service.
“In years four, five and six of our Targeted Investments program, we started to measure providers’ performance against a set of select HEDIS measures, including well-child visits, follow-up after hospitalization for mental illness at the seven-day and 30-day mark, metabolic monitoring for children and adolescents on antipsychotic medications, diabetes screening for people with schizophrenia or bipolar disorder who are using antipsychotic medications, and engagement of alcohol and other drug abuse or dependence treatment,” Snyder said.
The program has 13 justice clinic sites across the state, many of them are in the metropolitan areas of Maricopa and Pima Counties. They provide the full range of physical health services, behavioral health services, and probation and parole services on site in one clinic location, and are focused on connecting individuals to needed social services. In federal fiscal year 2020, more than 4,700 formerly incarcerated members received services through the integrated justice clinic sites.
A key element of the program is the establishment of a Quality Improvement Collaborative, that's working in partnership with Arizona State University’s College of Health Solutions and Center for Health Information Research. The Quality Improvement Collaborative supports providers participating in the Targeted Investments program in fostering their success in integrating care. It offers dashboards for providers, so they can see how they're performing on the various quality measures and offers assistance with quality improvement actions or interventions when they're attempting to address gaps in care, as well as peer learning.
A turning point
Snyder said the program has now reached a turning point. “We have appealed to CMS to continue the Targeted Investments program for an additional five-year period beyond the six initial years of the program,” she added. “We feel that in order to continue to be effective, we must extend our understanding of integrated care to not only include the provision of physical and behavioral health services, but also connecting individuals to critical social services when social risk factors are present. Our Targeted Investments 2.0 program is seeking waiver authority to extend the program from 2022 through 2027.”
The extension, she said, would help sustain the integration efforts of current Targeted Investments participants and expand integration opportunities to new providers, including Indian Health Services, and enhancing program incentives to focus on whole-person care under that extended understanding of integrated care. “We are looking at milestones such as screening for social determinants of health, connecting providers to our closed-loop referral system, which allows clinicians to more easily connect individuals to needed social services, and assessing for the prevalence of social risk factors and disparities across provider’s attributed lives.”
Another speaker during the webinar was April Rhodes, president and CEO for Spectrum Healthcare Group. Her organization started its integration journey back in 2009 in response to a study that showed that people living with serious mental illness were dying 25 years younger than the rest of the population. “At that time, as a community mental health center that was providing services to a very large population of people living with serious mental illness, we really felt that not only were we well-positioned to support those individuals in receiving physical health services, but really that we were responsible to do so,” she said. “We began with a very small subset of individuals living with serious mental illness, about 99 people, providing integrated care to them with a co-location contract with a local urgent care center. Since then, we've tried pretty much every type of integration model that you can imagine, arriving at our fully structurally integrated model that we have today.”
Rhodes spoke about Spectrum’s role as a Targeted Investments justice site. “We've been able to employ some really innovative and unique solutions to serve the justice-involved population. Targeted Investments has played an integral role in helping us to refine and shape that response to those justice-involved individuals.”
In Yavapai County, the county jail is located about 45 minutes away from the population center. Often people are being arrested and taken to jail and having to engage in probation services far from where they actually live, Rhodes explained. “Through our justice-involved efforts, we've been able to do a lot of really great things by co-locating at the jail and receiving people as they are released and connect them in real time — sometimes even in the parking lot in our mobile vehicles — to virtual primary care, on-site primary care, or providing transportation to a health home or provider that they may already be enrolled in. We've been able to do things like real-time assessments for behavioral health, substance use disorder, pain management, and primary care.” Spectrum also connects them with providers across the state and getting them rides to where they need to go, and then also assessing their employment and housing stability as a part of that. “It's been really great to have that support from Targeted Investments to be able to innovatively think about how can we solve for these unique situations people are going through.”
What has Arizona seen in terms of outcomes and opportunities in its efforts to transform the delivery of care? “We certainly have seen co-location occur between behavioral health and primary care providers,” Snyder said. “We've also seen coordination around payment of behavioral health services in primary care, additional levels of engagement for justice-involved members, behavioral health support in the process of offering chronic disease management, a clear focus on high-risk members.” She added that they also are seeing a bridging of the gap between the cultures that have historically existed between the provision of physical and behavioral health services. “I am happy to report — and this is hot off the presses — that we have data from our interim evaluation of our 1115 waiver over the first five years of the waiver period, and Targeted Investments providers have outperformed non-Targeted Investment providers in some key metrics, including the initiation of alcohol and drug abuse dependence treatment, the engagement of beneficiaries and ensuring that individuals with opioid use disorder are able to obtain medication assisted treatment.”
Rhodes called the Targeted Investments program a huge support for organizations working on behavioral health integration efforts in Arizona. “Having AHCCCS [the Arizona Health Care Cost Containment System] say this is a priority and we're going to transform the system to support those efforts was certainly a game changer for Spectrum as we were navigating incredibly challenging times from a financial perspective,” she said. “On paper, it seems like OK, we'll get psychiatry and primary care together in the same room, and they're just going to organically want to do this work together. But it doesn't happen that easily. When the system is reset to support integration at this level, that changes everything for the provider organizations. It drives that collaboration.”