Money Matters Webinar Objectives

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Prevention Research Centers (PRC)-Healthy Aging Research
Network (HAN) Webinar Series
Money Matters: Funding and Sustaining
Evidence-Based Depression Programming
November 13, 2008 3:00-4:30 EST
Moderated by:
Alixe McNeill, MPA
Liz Gitter, MSSW,
LISW-S
Chris Imhoff
Not pictured: Doris Clanton, Esq., MA, JD
Shelagh A. Smith,
MPH, CHES
Sponsors
Prevention Research CentersHealthy Aging Research Network
http://www.prc-han.org/
Retirement Research Foundation
http://www.rrf.org/
National Council on Aging
http://ncoa.org/index.cfm
Money Matters Webinar Objectives





Understand successful grant funding strategies for training
and implementation of evidence-based depression care
management programs.
Learn about the actions three states have taken to foster
community start-up of Healthy IDEAS and PEARLS.
Learn about public reimbursement for mental health
services in primary care (such as IMPACT) and community
settings.
Learn about billing strategies for depression care
management.
Understand how others have funded evidence-based
depression care so that your agency is able to develop
funding options and plans.
Funding for Community Depression Care
Examples: Healthy IDEAS and PEARLS



Program development and research funding:
– John A. Hartford Foundation, AoA
Dissemination funding to date:
– AoA, CDC, SAMHSA, Retirement Research
Foundation, State of Washington
– Academic partner resources through University
of Washington and Baylor and Baylor VA work.
State and Local implementation funding includes:
– AoA, SAMHSA, CMS, AHQR, NIH,
– States, Foundations and Local Government
Financing Sources
July 2008
* multiple funding
sources.
Healthy IDEAS
PEARLS
(approximate number of
local sites)
AoA – OAA
R&D Choices Prevention
(time limited grant)
7 sites: TX (3), NJ (2),
OH* (1), MD* (1)
State SUA / Local AAA OAA National Family
Caregiver
(Potentially
sustainable?)
6 sites ME*,
State SUA / Local AAA –
OAA Title 3 – Services,
Health Promotion
(potentially sustainable)
2 sites MD*, VT*
AoA – OAA
Alzheimer’s
Demonstrations
(time limited grant)
1 site ME
(State with reach to 5
AAAs)
2 sites WA
(AAA discretionary)
Financing Sources
July 2008
* multiple funding
sources.
Healthy IDEAS
PEARLS
(approximate number of
local sites)
SAMHSA
MH Transformation
grants
(time limited)
4 sites MI, OH *
(training and
operations)
SAMHSA Targeted
Capacity Expansion
(TCE)
(time limited)
Applications pending in
July
Applications pending in
July
CMS/State - Medicaid
case management
waiver
(sustainable)
6 sites FL, GA, ME, NJ,
OH * VT
(some training only /
some training and
operations)
1 site WA
(training and
operations)
CMS – Medicare
(sustainable)
1 site NJ
(pays for counseling
portion of intervention
Financing Sources
July 2008
* multiple funding
sources.
Healthy IDEAS
PEARLS
(approximate number of
local sites)
CDC - Dissemination
(time limited)
1 or more sites WA
AHQR –Healthy States
(time limited)
1 site VT (facilitated –
may have supported
adoption)
NIMH/NIH
1 site PA (expanded
model in study)
State Funding –
(some of this funding
may have federal origin
in MH block grants or
other sources ) –
AZ MH prevention
GA suicide prevention
ME, MI training
Foundations - Regional
4 in FL, NJ, TX
Local government
2 sites WA – county
levy
Mini-grants Fund
Healthy IDEAS
in Ohio
Liz Gitter
GitterL@mh.state.oh.us
614-466-9963
What We Did


Implemented a mental health evidencebased practice (EBP) in an aging
Home and Community Based Service
(HCBS funded by Medicaid) to seniors who
met levels of care for nursing homes.
Used funding from federal grant & 3 state
agencies to fund mini-grants for start-up
costs for Healthy IDEAS and other
EBP/promising practices.
Get Buy-In




At state level – held two policy institutes –
stakeholders heard national speakers,
developed goals with action steps and
prioritized
Asked state dept. directors to speak
Local stakeholders – aging, behavioral
health, health, adult protective services
Consumer and family organizations
Older Ohioans Behavioral
Health Network
 County
MH/SA boards approached
Ohio Dept. of Mental Health to
address seniors as underserved and
growing population
 Ohio
received funding from SAMHSA
for Mental Health Transformation
State Incentive Grant (TSIG)
 TSIG
supports infrastructure change
State Collaborations

ODMH provided initial funding with aging and substance
abuse dept. contributing small amounts

Six state dept. directors signed letter of commitment

Established trust and learned each others’ language----i.e.
“depression” not “mental illness”

Created Older Ohioans Behavioral Health Network— state
human service agencies, providers, consumers, families
http://www.oacbha.org/programs/older_ohioans.html
Contact: FFleischer@oacbha.org Frank Fleischer
Ohio Association of County Behavioral Health Authorities
614-224-1111
Local Collaborations


Locals identified and secured small
amounts of funding from additional
sources (state departments, hospitals,
foundations)
Older Ohioans gave several rounds of
mini-grants to 11 Area Agencies on Aging
(AAA) mini-grants to organize local crosssystem collaboratives to do needs
assessment/resource inventory
Mini-Grants Requirements


Brief application (6 pages) to Older
Ohioans with aging, MH, and consumers
reviewing
Requirements for mini-grant
–
–
–
–

Regional collaboration MH/SA and Aging
Evidence-based or promising practice
Support recovery (consumer choice)
No funding for direct services
Awards $4,000 - $10,000 – most at lower
end
(cover start-up (i.e. training only)
Mini-Grants

Local AAAs and MH/SAs selected EBP and
promising practices to implement
– Healthy IDEAS
– I – Team – care coordination
– Web-based primary physician training on
depression, dementia and substance abuse
– Pilot training home-health aides on MLDT
depression and memory impairment.
– Pilot promising practice harm reduction of
hoarding
AAAs Implement



Passport program implements Healthy
IDEAS as part of assessment by nurses
and social workers. (Passport is HCBS
alternative delivered by aging system.)
For identified clients, intervention by Area
Agencies on Aging nurse or social worker
as part of Passport
Staff reports Healthy IDEAS great tool,
decreased client depression, minimal
change to work load.
Sharing Across Ohio and USA
 Developed
Ohio tool kit with
information on CD and in notebooks
 Implementation
staff present at
statewide and regional aging
conferences
 Reporting
 Sharing
to SAMHSA via TSIG
nationally through meetings
and webinars
National Healthy Ideas Resources
Needed for Local Implementation

Healthy IDEAS

website:
http://careforelders.org/index.cfm?menuitemid=290

Contact Esther Steinberg, at
Esteinberg@shelteringarms.org or 713.685.6579
Webinar on Healthy IDEAS
http://www.ncoa.org/content.cfm?sectionID=379&detail=260

Thank you!
Georgia Strategies
Doris M. Clanton, Esq.
dclanton@dhr.state.ga.us
Georgia Department of Human Resources
Division of Aging Services
Background

Georgia
– 2003 Data: DHR/MHDDAD GAP Analysis – older
adults special population - underrepresented and
underserved
– The DHR Division of Aging Services (DAS, or SUA) and
Division of Mental Health, Developmental Disabilities and
Addictive Diseases (MHDDAD, or SMHA) collaborations
with the Fuqua Center for Late-Life Depression of the
Emory Healthcare and others on three projects serving
older adults


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CCSP Depression Screening (Healthy Ideas)
Geriatric Telemedicine
Older Adult Peer Support Specialists
– Atlanta Area Coalition on Aging & Mental Health
– Georgia Coalition on Older Adults and Mental
Health
Healthy Ideas

Georgia Department of Human Resources, Division of
Aging Services (DAS), Community Care Services
Program (CCSP) Depression Screening
– Statewide Depression Screening for participants in the Community
Care Services Program [Medicaid waiver program, 1915 (c)]
providing intervention to help (1) identify those at risk; (2)
identify areas lacking in mental health services; (3) train care
coordinators to recognize signs and symptoms and discuss with
primary care physicians; and (4) obtain resources to provide
services;

Two lead care coordinators (case managers) in each of the 12 Planning
and Service Areas (PSAs) trained in Healthy Ideas; designated
Psychiatric Care Specialists.
– Key Partners: Fuqua Center for Late-Life Depression (Emory
University), DHR Division of Aging Services (SUA), the 12 Area
Agencies on Aging (AAAs) and their Care Coordination Agencies
– Funding: Early American Foundation on Suicide Prevention grant
provided to Atlanta Regional Commission AAA; SUA replicated
statewide, progressed to EBPs and Healthy Ideas, Care
coordination state funding for training.
PEARLS
Two Georgia Coalition on Older Adults and Mental Health Member
agencies funded technical assistance on PEARLS training at
University of Washington (9/24-26/08) –

Central Savannah River Authority (CSRA)
Area Agency on Aging
– Funding: AAA budget, Older Americans Act funding

Georgia Association of Homes and Services
for the Aged (GAHSA) and the Fuqua Center
for Late-Life Depressions
– Funding: Georgia Medical Care Foundation grant to
GAHSA for low income older adults residing in high rises
in Metro Atlanta area, for screening, referral and
problem-solving
Successful Collaboration

Georgia - Older Adults Peer Support
Specialists Training Project
– Builds upon Georgia Consumer Mental Health
Network training and their successful Certified
Peer Specialist (CPS) program for older adults
peers and consumers
– Key Partners: DHR DAS (SUA), DHR
MHDDAD (SMHA), Georgia Mental Health
Consumer Network, Appalachian Consulting
Group, and the Fuqua Center for Late-Life
Depression
– Funding: Fuqua private donor for focus group,
small part of a CMS Real Choice Systems
Change grant (for SMHA) used to train first
volunteers
Additional Training

Depression and Mental Health Training
Provided by for DHR Public Guardianship
(Adult Protective Services case managers),
GeorgiaCares (SHIP), and LTCO
– Partners: Training provided by the Fuqua Center of Late
Life Depression. Organizers included DAS GeorgiaCares,
DAS Public Guardianship
– Funding: State funding for public guardianship (DAS)
and part of GeorgiaCares (SHIP) mental health outreach
funding (5% set aside) through CMS

Family Caregiver Support
The Future
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
Funding for future Healthy Ideas and PEARLS
training
Funding for older adult and mental health
training, including depression training for
Gateway (Information, Assistance and
Referral) for Aging and Disability Resource
Connection (ADRC)
– Would include Medicaid and Non-Medicaid
programs
Summary


Collaborate and Partner with Others (academia,
older adults, advocates, trailblazers, experts,
state and local agencies, MH and Aging
coalitions, MH Planning and Advisory Councils,
national associations, etc.)
Locate and Use available funding sources, even
if small (grants, government funding, etc.)

Identify Program Champions

Plan for Budget Shortfalls

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Provide for funding for Training, Retraining
and Support for EBP pioneers
Imbed EBPs within your program (Quality
of Care)
Plan for budget shortfalls
Encourage advocates and Mental Health
and Aging Coalitions to assist in acquiring
funding and outreach
Funding Opportunities
for Depression Care
Management :
Washington State’s
Experience
Chris Imhoff
imhofc@dshs.wa.gov
360-725-2272
Depression Prevalence Among those
served by Washington’s AAA Network



Based upon CES-D (11) scores,
approximately 35% (5,500) of the
Medicaid LTC in-home clients over age 60
have indicators of minor depression
27% have indicators of major depression
20-50% of informal caregivers report
depressive symptoms or disorders
Funding for 1st PEARLS Project

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Development of Evidence
University of Washington Health Promotion
Research Center partnered with Aging and
Disability Services of King County (AAA)
5-year Center for Disease Control (CDC)
for randomized clinical trial
How are AAAs Currently Funding
PEARLS?



Older Americans Act Funding IIIB
Older Americans Act Funding IIIE (Family
Caregivers)
County Levy Funding for veterans and
individuals with chronic health conditions

Nursing Home Diversion Grant – July 2009

State Funding
PEARLS Implementation Toolkit
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Mental Health Transformation Grant
Funding to develop an implementation
toolkit to facilitate dissemination
University of Washington’s Health
Promotion Research Center developed the
toolkit
Available through Washington State’s
Aging and Disability Services
Administration
Future Funding Ideas - Medicaid

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1915(c)(1) Medicaid Waiver as allowed under the
Social Security Act
CFR 440-180(b)(9) – Other services requested by
the agency and approved by CMS as cost
effective and necessary to avoid
institutionalization.
Washington’s COPES waiver includes
Recipient/Caregiver Training
Potential to define case management as a service
under waivers which may be a fit for specialized
types of case management
Future Funding Ideas – OAA and
Project 2020


Authorizing language includes work on
disease prevention and health promotion
Potential to fund EBPs such as PEARLS or
Healthy IDEAS
Public Reimbursement for
Mental Health Services In
Primary Care and
Community Settings
Shelagh A. Smith, MPH, CHES
U.S. Department of Health and Human Services
CMS/HRSA/SAMHSA Workgroup




The New Freedom Commission on Mental Health
Report (2003)
Federal Action Agenda and workgroups to followup recs on financing and integration of services
issues.
Steps included identification of known financing
barriers and seeking the input of those in the
field.
Our approach – provide specific information for
states and providers to use.
Barriers Identified by the Expert Forum,
Apply to Medicare and Medicaid
1. Limitations on payments for more than one visit on the same day;
2. Lack of reimbursement for components of the collaborative care
model related to mental health services;
3. Absence of reimbursement for services provided by some nonphysician providers and contract providers;
4. Medicaid disallowance of reimbursement when primary care providers
submit bills listing a mental health Diagnosis & corresponding
Treatment;
5. Low reimbursement rates in rural / urban settings;
6. School-based health center settings;
7. Lack of reimbursement incentives for screening & preventive MH
services

See page 2-3 of Reimbursement of MH Services in Primary Care Settings, SAMHSA, 2008
Primary Care Initiatives and the
Collaborative Care Model

Providers may use evidence-based components of a “care model”. See p.
20 of SAMSHA report

Components of Care Models may include:
–
–
–
–
–
–
–

Community
Health System
Self management support
Delivery system design
Decision support
Clinical information systems
Care Manager or Care Coordinator
Examples of initiatives:
– Robert Wood Johnson’s Depression in Primary Care Program
– IMPACT Model for Collaborative Care (Katon, et. al., Diabetes Care,
February 2006) See Lorig et al 2001; Noel et al 2004; Unutzer et al
2002)
– HRSA Bureau of Primary Health Care’s Depression Collaborative
Key Requests Made By Forum
Participants




Identify and disseminate successfully used
mental health billing codes.
Develop a project to describe specific services
and reimbursement codes for collaborative care.
Coordinate with States that want to develop
contract terms for MBHOs to include PC providers
in networks.
Strengthen service integration, links & referrals
to specialty care settings (e.g., on-site
consultation and referrals for rapid care).
What Are Our Action Steps To Address
The Barriers?



Create a forum for dialogue among State
Medicaid Directors, State Mental Health
Directors, and Safety Net PC Providers
Recognize States and MBHOs that appropriately
include primary care providers in their provider
networks.
Describe the evidence-based components of
“care model” (incl. service definitions and
reimbursement codes).
How to Get Collaborative Care
Services Covered



CMS pays for services, not models
Medicaid service- State decision; must be in
State plan or under Medicaid waiver. (see p. 21 of
report and section 1915(g) of the Social Security
Act)
Medicare service- Bill under CPT codes via
Evaluation and Management service code or HBAI
codes
Identifying Successful Codes Used
in States



States can benefit by sharing information on
what billing strategies work;
See our website:
http://hipaa.samhsa.gov/hipaacodes2.htm
11 States provided the codes and providers that
are allowed in their state to bill for MH services:


Level I - “Current Procedural Terminology (CPT)” Codes
(AMA maintains) - Used more often by Medicare
Level II - “Healthcare Common Procedure Coding System
(HCPCS) Codes (CMS maintains) - State Medicaid H and T
codes
Coding…CPT codes

Current Procedural Terminology:
– CPT - Level I. ( AMA maintains since 1966)
– Consist of 5 numbers; + sometimes a 2-digit modifier
– Psychiatric Codes, 90801 – 90899, for licensed or
certified MD and non-MD MH specialists, like CSW or
psychologist
– Evaluation & Management Codes for MDs/ NPs to use
with ICD-9-CM diagnosis
– Health Behavior Assessment & Intervention ( HBAI)
Codes for Non-physician MH specialists, w/ ICD-9-CM
– SBI Codes for qualified providers to conduct brief SU
Claim Tips for Primary Care Providers from
the Mid-America Coalition on Health Care
Tip #1: Diagnosis Codes

311 - Depressive
Disorder


296.90 - Mood
Disorder


300.00 - Anxiety
Disorder

296.21 - Major DD,
Mild

296.22 - MDD,
Moderate



296.30 - Major DD,
Recurrent
309 - Adjustment
Disorder with
Depressed Mood
300.02 – GAD
293.83 - Mood
Disorder due to
Medical Condition
314 - ADHD
Tip #2: Evaluation and Management
(E/M) CPT Codes


MDs/NPs may use E/M CPT codes 99201–99205
or 99211–99215 (Office visit codes) with a
primary diagnosis of depression claim with any of
the ICD-9-CM diagnosis codes above in Tip #1.
Do not use psychiatric or psychotherapy CPT
service codes (90801–90899) with a depression
claim for a primary care setting. These codes
tend to be reserved for psychiatric or
psychological practitioners only.
(Mid-America Coalition on Health Care, 2004; cited p.16 in Reimbursement of
MH Services in Primary Care Settings, SAMHSA, 2008)
States’ Reports of Most Successful MH
Service Codes


The EM CPT outpatient service codes for
consultation or office visits are to be used
by MDs in the community care setting;
use with an ICD-9-CM primary psychiatric
or medical diagnosis.
EM codes : Used w/ ICD-9 diagnostic
code, by MDs or NPs
 Office:
99201 – 99125
 Consult: 99241 – 99255
(--State of Arizona, Medicaid office, 2006)
Newer Types of MH CPT Codes Used
with Primary Physical Diagnosis
Health Behavior Assessment & Intervention (HBAI)
Used w/ ICD-9 ( Medical Primary dx) by nonphysician Mental Health/ Behavioral specialist
(certified by State)
–
–
–
–
–
–
96150
96151
96152
96153
96154
96155
–
–
–
–
–
–
HBA interview or monitoring, 15 minutes
Reassessment
Individual HB Intervention, 15 minutes
Group Intervention
Family ( with patient)
Family (without patient)
CPT Level I Codes, Cont’d

Screening for Substance Use and Brief
Intervention:
•
•
•
99408 (screen) & 99409
(intervention) – Private insurer
H0049 & H0050 – Medicaid
G0369 &G0370 – Medicare
For a discussion of possible reasons for variability in
interpreting claims, see pages 26-27 of SAMHSA
report.
Resources on Billing for Collaborative
Care & MH Services

SAMHSA Website:
 http://hipaa.samhsa.gov/hipaacodes2.htm

CMS Mental Health Website:
 www.cms.hhs.gov/MHS
• SAMHSA report :
http://download.ncadi.samhsa.gov/ken/pdf/SM
A08-4324/SMA08-4324.pdf
Questions: Shelagh.smith@samhsa.hhs.gov
Shelagh.smith@samhsa.hhs.gov
Thank you!
Questions & Answers
Final PRC-HAN Webinar:
Coming in December!
Evidence-Based Depression Care Programming
and Best Practices for Older Adults in a Public Service
Delivery Setting – Mental Health – Aging Network
– Public Health
Speakers: Stephen J. Bartels, Suzanne R. Bosstick,
Margaret Moore
Check back soon to Register at:
http://ncoa.org/content.cfm?secti
onID=64
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