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 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 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 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 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 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 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
