A How To Guide: Partnering with Health Homes and ACOs

by Rebecca Farley on March 10, 2011

Welcome to our live webchat with guest bloggers Dale Jarvis and Laurie Alexander on partnering with health homes and accountable care organizations! On March 23, Dale and Laurie took readers’ follow-up questions from their webinar on the same topic, which provides an in-depth look at what steps mental health and substance use providers need to take in order to ensure their readiness to efficiently and effectively partner with these models.

Although this event has now concluded, the questions and answers will remain on the blog for you to reference at any time.

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{ 51 comments… read them below or add one }

Lori Doyle March 22, 2011 at 6:59 am

Are there any states that have amended their state plan to include behavioral health providers as medical homes? if so, do they have criteria for deciding which behavioral health providers can become medical homes?

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Dale Jarvis March 23, 2011 at 12:52 pm

There is a multi-part answer to this question.
A state doesn’t have to amend its state plan to designate who gets to be a medical home. It just does it.
If a state is selecting a Section 2703 Health Home Option where it get’s paid 90% federal share (10% state) for health home services, it needs to come up with a plan to identify which Medicaid enrollees will be included and what organizations qualify has health homes. I know that Missouri has submitted their application and I’m not sure whether other states have yet. I don’t know whether Missouri included BH providers. New York’s BH providers have submitted a proposal to the state to include them as health homes. That’s all I know now.

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Michael March 22, 2011 at 12:56 pm

In my area of Florida, we have several med homes who are staffed primarily with medical providers (i.e. Drs., D.O.s, Dentists, RNs, LPNs, etc.). Are med homes utilizing licensed behavioral health practitioners (i.e. ARNPs, psychiatrists, LPCs, LMHCs, LMFTs, LCSWs) more frequently? Thank you.

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LaurieAlexander March 23, 2011 at 12:51 pm

Yes, I would say behavioral health providers are more likely to be involved in health homes now than they were previously. The critical role of mental health and substance use care in ensuring overall health is becoming more clear to folks in the health care field working on health homes, and I think we’re seeing that reflected in the make-up of health homes. If it hasn’t happened in your area yet, it sounds like you’d be in a great position to make the case for mental health and substance use being at the table!

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Debbie March 23, 2011 at 7:50 am

How do we find out who gets selected in our area to be a home health provider? Is there a state of local website? We can’t apply if we don’t know who they are.

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LaurieAlexander March 23, 2011 at 12:55 pm

Thanks for your question, Debbie. Participating in a health home doesn’t happen through an application process. (Phew!) It happens by reaching out and forming relationships with primary care providers in your area who have or are developing a health home. Once you make the connection with the primary care leaders in your area, you’ll want to make the case for how your organization is prepared to be an effective partner in the health home, but no formal application necessary! And it’s also important to note that mental health and substance use providers can also create their own health homes. If that’s something you’re interested in, the National Council has some really nice resources for learning more.

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Rebecca Farley March 23, 2011 at 12:59 pm

Please visit the Collaborative Care page of the National Council’s website to read our reports on Accountable Care Organizations and healthcare homes: http://www.thenationalcouncil.org/cs/collaborative_care

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Nadine March 23, 2011 at 11:02 am

How does the shortage of PCPs influence the develoment of ACO’s?

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Dale Jarvis March 23, 2011 at 12:58 pm

This is a huge problem – not enough primary care physicians, primary care nurse practitioners and primary care physicians assistants. There is a move underway to designate specialists as medical homes who do primarily office-based care (versus primarily surgery), who manage patient care on an ongoing basis. Think cardiologists who work with folks with serious heard disease and, in real life, are there primary care provider. There is also a big push to build the teams in primary care clinics, adding nurse practitioners, health coaches, behavioral health clinicians, etc. to be the equivalent of physician extenders to address this problem. Medical schools are reporting that more young folks are choosing primary care. This problem may take 10 years to solve.
The last comment is that Group Health Cooperative in Seattle, which is already a ACO by virtue of being a HMO has turned into a really attractive place to work because it’s moving quickly to make all of their clinics medical homes and telling doctors that they have 30 minute appointment slots to see patients. Those that become successful ACOs first will steal PCPs away from other places.

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Harry Reyes March 23, 2011 at 12:12 pm

In the developing of an ACO that includes an FQHC, what is the fiscal sharing when the FQHC is reimbursed at a much higher rate than a CBO?

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Dale Jarvis March 23, 2011 at 1:01 pm

This is still to be worked out. Some FQHCs are having the CBO staff bill through the FQHC in order to draw down the prospective payment for the CBO staff who become contractors to the FQHC. There are a number of hoops that must be jumped through to make this happen. If an ACO get’s a global budget from health plans, it can decide what to pay the providers and how to deal with the bonus arrangement. If a CBO is seen as a valued organization, critical to the ACOs success, the ACO doesn’t have to live by the old rate schedule and can even dump fee for service and pay case rates or make a capacity-based payment.

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Michelle March 23, 2011 at 12:32 pm

I will refer to the mentioned resources after this presentation but is it required that a primary care physician is included in every health home? My understanding is that the core health home has a physician and specialty providers that create their own home are considered a health home neighbor, not a health home?

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LaurieAlexander March 23, 2011 at 1:00 pm

A primary care provider does need to be included in every health home. Primary care delivery is at the heart of health homes. However, a health home can be based in a primary care provider organization or in a behavioral health provider organization that has in-house primary care services. A specialty provider that creates its own health home would still be a health home.

A health home neighbor is a specialty provider that partners with the health home to provide specialty care. So, if a health home does not have mental health or substance use services in house (or has very limited MH/SU resources), they can establish a relationship with a behavioral health specialist to provide that care. That behavioral health specialist would be considered a health home neighbor.

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Michelle March 23, 2011 at 12:33 pm

You mentioned “designated primary care provider,” how is this defined?

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LaurieAlexander March 23, 2011 at 1:05 pm

Every patient in a health home has a designated primary care provider who heads up a care team that has responsible for seeing that the patient gets the health care they need. I think of the designated PCP as the hub of a health care wheel with many spokes. So, the patient may also see a diabetes educator, an on-site psychotherapist, and an oncologist, but it is the designated PCP and his/her team who serves as the hub for all the information that is being generated about that person’s care and makes sure that the person’s overall health is being well addressed.

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Michelle March 23, 2011 at 1:09 pm

Thank you Laurie, for your reply. Is there a specific definition of who qualifies as a PCP, i.e. need it be a physician? Is this specifically outlined in the ACA?

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LaurieAlexander March 23, 2011 at 1:24 pm

The ACA does not specify the credentials of the PCP, and I haven’t seen other language on that. Instead of a primary care physician (MD etc.), it could be a nurse practitioner or related professionals depending on the laws in your state etc.

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John Craik March 23, 2011 at 12:36 pm

New York State will probably create regional Behavioral Health Organizations to manage behavioral health care costs and coordinate services — what is the relationship between BHOs and ACOs, an and how should a mental health provider prepare for both?

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Dale Jarvis March 23, 2011 at 1:09 pm

You are describing a state where behavioral health is carved out and you have health plans managing health and behavioral health plans managing behavioral health.
Here’s what I think needs to happen. Both types of plans should agree to contract with ACOs that provide the full range of care. BHOs will pay for their stuff and health plans will pay for their stuff – all through the ACO. If the two types of plans work together they can push integrated care. If the BHO doesn’t do this it will keep the BH community outside the ACO setting and everyone loses. This is a huge issue and I don’t know how many BHOs are tracking this.

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John Craik March 23, 2011 at 1:38 pm

Thanks Dale, I’ll see you in Albany near the end of April.

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Dale Jarvis March 23, 2011 at 2:00 pm

Thanks for your question. This helps me think about what I want to talk about when I’m there.

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Ellen Healion March 23, 2011 at 12:37 pm

How does PROS fit into all of this…..will it cease to exist with the expectation that it will fold into ACO or Health Homes?

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LaurieAlexander March 23, 2011 at 1:05 pm

Could you clarify what PROS is? Thanks!

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Ellen Healion March 23, 2011 at 1:19 pm

PROS is Personalized Recovery Oriented Services
It is a medicaid reimbursable program that NYS Office of Mental Health rolled out in 2006/7 . It was meant to relieve NYS of the cost of contracts for rehabilitation services.

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Ellen Healion March 23, 2011 at 1:22 pm

PROS also can include Clinical services (which we are providing)
We are also a Peer Run Organization how does that play into anything- or does it?

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Dale Jarvis March 23, 2011 at 1:32 pm

Thanks. I spent last week with Harvey Rosenthal and have a much better idea of what a PROS is; just forgot the acronym.
Here’s my prediction: Some ACOs will understand how critical PROS are to achieving the triple aim for folks with behavioral health disorders. They will seek out and bring those PROS into their ACOs. They will succeed fabulously, as long as the PROS learn to work well with their medical partners. If the cultural gaps aren’t bridged, things could go south, to everyone loss. This is going to be a challenge because of the differences in how many doctors approach prescribing of psychiatric medications, compared to how many in the peer movement think about this: medicate first and maybe add recovery supports; versus provider recovery supports and then add meds if needed.
For ACOs that don’t understand the importance of PROS, they will not succeed. I think it’s that simple, but time will tell.

Ben Henwood March 23, 2011 at 12:37 pm

Can mental health agencies (funded through mental health dollars) become a medical home by partnering with larger medical centers? What different types of obstacles exist (legal, financial, etc)?

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LaurieAlexander March 23, 2011 at 1:11 pm

Yes, a mental health provider can become a health home either by developing their own primary care / health care delivery capacity or by partnering with a health care provider (e.g., a larger medical center) that already has that capacity.

If a mental health chooses to become a health home in partnership with a medical provider, there is a whole host of issues that need to be ironed, as you identify — legal, financial, etc. There need to be agreements around how care will be delivered, how information will be shared, how payments will be processed etc. The National Council has some nice readings on their website that get into some of these issues.

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Rebecca Farley March 23, 2011 at 1:15 pm

The National Council has issued reports on Behavioral Health/Primary Care Integration and the Healthcare Home, Substance Use Disorders and the Healthcare Home, and the report referenced in today’s webinar, Partnering with Health Homes and Accountable Care Organizations. All of these resources, along with information about the Medicaid Health Homes State Plan Option, are available on the Collaborative Care page of our website: http://www.thenationalcouncil.org/cs/collaborative_care

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ed March 23, 2011 at 12:39 pm

Who determines service mix if we’re under an ACO? And what will the funding mechanisms be for the service mix? Who will be responsible for making the different IT EHR softwaare programs talk to each other?

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Dale Jarvis March 23, 2011 at 1:14 pm

Generally, a well functioning ACO will answer the following questions: Who’s my population? What type of care do they need? How much?
They should then organize their ACO network to ensure that the right amount of the right kind of care provided by the right providers is available to the members of the ACO. If not, the ACO won’t be able to achieve the triple aim.
The ACO has a huge responsibility to integrate the software from all of the different vendors. There are some cool projects around the country. Whatcom County Washington (Bellingham) is a community that is further along than most places. Take a field trip out here.

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Katy March 23, 2011 at 12:39 pm

We have a specialty clinic serving the chronically mentally ill. We have recently brought primary care services into our facility to serve that specific population. We partnered with a FQHA. Given the ACO model, would this be deemed as home health? And would we be able to partner with multiple ACO’s?

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Dale Jarvis March 23, 2011 at 1:17 pm

This is a tricky and important question. You definitely want to try and get the primary care clinic in your center recognized by NCQA as a patient centered medical home. This may or may not be possible, depending on how robust your health home is. If yes, then you’re part of an ACO as a health home. You also provide specialty care. I anticipate that in this case you could be a member of a single ACO as a health home and a member of multiple ACOs as a specialist. This is very complicated, but does it make sense?

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Katy March 23, 2011 at 1:59 pm

Yep. Makes perfect sense. Thanks.

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Ivan Anderson March 23, 2011 at 12:39 pm

What if my county is already in the process and collaboration of the ACO’s and the CEO’s of the hospitals and dealing with Mental Health and Substance Abuse issues in the provider’s care?

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Dale Jarvis March 23, 2011 at 1:20 pm

That’s probably very good news, as long as they are approaching this from the perspective of, “we can help you succeed in achieving the triple aim for patients in the ACO.”
I would also try to get to that same table to sell your organization as a value added partner (assuming you’re not the county). They need to get to know you and your organization and how your organization can help them succeed.

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Linda Hammond March 23, 2011 at 12:43 pm

Where do free-standing psych hospitals fit with regard to ACO development?

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LaurieAlexander March 23, 2011 at 1:12 pm

Free-standing psychiatric hospitals would be considered a specialty “clinic” within the ACO, and should certainly be contacting stakeholders in the community to discuss partnering in an ACO.

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Michelle March 23, 2011 at 12:46 pm

Will health plans/insurance companies no longer have panels that individual mh/su providers need to be on in order for clients to have coverage? And does that mean that providers will in a sense be on the “panel” of an ACO instead? It seems this concept of an ACO is creating a “middle-man”?

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LaurieAlexander March 23, 2011 at 1:17 pm

I’d look at a little differently. Instead of there being payers that pay primary care providers and payers that pay MH/SU providers, payers will pay ACOs, which will organize the care delivery for the population it serves. To participate, the MH/SU provider will have to be either a member of the ACO or a “preferred provider” (separate from the ACO but with contractual arrangements).

In terms of the “middle man” issue, it may help to remember what we talked about in terms of the triple aim. ACOs will be incentivized to provide whatever care is necessary to optimize quality and patient experience while reducing costs. That’s different from an entity that’s focused primarily on the cost aspect. Hope that’s helpful!

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Liz Earls March 23, 2011 at 12:51 pm

Rhode Island’s community mental health system is pursuing Medicaid health homes — we believe that much of what we have been doing formally and informally – often without financial support – meets health home service specifications. So we are looking at some of our core service codes under our community support services, i.e. community psychiatric support, ACT, and identifying the services within these codes that meet health home criteria for comprehensive case management and care coordination. Are other states approaching similarly?

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Dale Jarvis March 23, 2011 at 1:37 pm

Hi Liz. New York is pitching this idea. I don’t know if other states are moving down this path, but I’m guessing that BH stakeholders are working on this.
Here’s the catch. For a CMHC to be a true health home, it needs to make sure that their clients get all of the primary care needed, preferably under the same roof; if not under the same roof, to make have health navigators who accompany clients to doctor visits to help ensure that they get what they need from the medical clinic to help them address all of their health conditions. If your health homes don’t do pap smears for women and prostate exams for men (or ensure that they occur), they can’t really call themselves health homes. Does this make sense? Did I not fully answer your question?

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Karl V. Kovacs March 23, 2011 at 12:55 pm

Can an ACO be a service providing organization or a provider sponsored organization?

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Dale Jarvis March 23, 2011 at 1:25 pm

There will be many flavors of ACOs. The intent is to push the responsibility for achieving the triple aim down to the delivery system level; as opposed to having health plans be in charge of all this – inspectors looking over the shoulders of the folks who provide the actual services. This is basic “quality 101″.
As such, it’s been anticipated that ACOs would be created and managed by the delivery system. If the organization is large enough to have all of the needed clinician types, an ACO can be a service providing organization. If there need to be multiple organizations to cover the span of care, it would be a provider sponsored organization.

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Robert Culleton, Ph.D. March 23, 2011 at 1:01 pm

My question is similar to that posed by Ivan Anderson above. I am organizing county directors of alcoholism and drug abuse for purposes of planning the expenditure of liquor tax dollars in their counties. Traditionally, they have spend their shares on providing treatment access. If access is assured through insurance, the county director’s can spend much more of their dollars on prevention and recovery support services. I also am trying to prepare them for the impacts of HCR, which as you say, will take unique shape in each locale. What can county planners do to guide development of HCH’s in their jurisdictions?

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Dale Jarvis March 23, 2011 at 1:44 pm

Good questions. Many drug and alcohol treatment providers don’t have the infrastructure in place to bill Medicaid and insurance companies. Many providers don’t know how to practice in health homes using models like SBIRT and medication assisted treatment. The community of substance use disorder treatment providers needs to assess their readiness as the head is reconnected to the body, identify gaps, and begin filling those gaps. Much of what NIATx has been doing is healthcare reform readiness prep. If I were a county planner, I would get my Readiness Assessment and facilitate a group process with all of my providers to complete it, identify where there are common gaps, and support your providers in filling those gaps. Write me at dale@djconsult.net and I’ll send you a copy.

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ed March 23, 2011 at 1:01 pm

How will Quality of Life/Recovery be dealth with by ACOs. The medical world really looks for only stabilization and symptiom reduction. If it costs an extra dollar to help a person e.g. get a job will they spring for it?

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Dale Jarvis March 23, 2011 at 1:54 pm

Those who set the performance measures and bonus arrangements will drive the answer to your question. Medicare will set the ACO performance measures for Medicare ACO pilots. States will set ACO performance measures for Medicaid programs and probably the Health Insurance Exchanges. Health plans will set the ACO performance standards for their enrollees. Self-insured employers will set the ACO performance standards for their employees. I think there will be a convergence of measures over time. For the 150+ million folks getting employer-sponsored healthcare, absenteeism and poor productivity is huge and relates to quality of life and recovery. I’m optimistic. If I’m right, ACOs will be funding much more than straight medical care sooner or later.

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Stacey McCarthy March 23, 2011 at 1:04 pm

If I understand things correctly (which I may not), because of the DOJ lawsuit against the state of GA, there is federal money coming into the state for housing.
Will there be coordination between that money and this concept? By whom?
If community MH providers are responsible for developing relationships with other medical providers to form a ACO, and it’s going to be a health “home”, it would seem like money targeted to improve housing would factor in somehow.
Not sure how……………………….or who to talk to about it…………..

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Dale Jarvis March 23, 2011 at 1:58 pm

Here’s what ought to happen. We need to focus money for health, behavioral health, employment, child welfare, oral health, housing through ACOs that serve folks in the safety net including those with behavioral health disorders. This will drive blowing up the silos and create a situation where each person has only one care plan, one care team, and one health record that covers all of the services and supports in the care plan. This includes addressing and paying for everything on my list above. Until we get here, people with multiple and complex conditions will continue to get fragmented and consumer unfriendly care. This is a big challenge. Georgia should be one of the first states to try and make this happen. Washington and Oregon are already headed in this direction.

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Rebecca Farley March 23, 2011 at 1:35 pm

Thank you for participating in today’s webchat with Laurie Alexander and Dale Jarvis! We have run out of time for this event today, but please check back over the next week as Dale and Laurie respond to any questions they were unable to get to today. The slides and recording from our “Partnering with Health Homes and ACOs” webinar will be available soon on the National Council’s website at http://www.thenationalcouncil.org/cs/recordings_presentations.

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