Managing mental health along with medical care
Separate departments join forces to coordinate care
Coordinating the case management for mental health problems with medical case management has paid off for a Medicaid managed care organization.
HealthSource/Hudson Health plan in Tarrytown, NY, has the highest scores in the state in two of three quality indicators for mental health services monitored by the New York State Department of Health. The organization does not have enough members to qualify for the third indicator.
"Our ability to score so high on quality indicators for the state has everything to do with the medical case management and mental health care management working together," says Margaret Leonard, MS, RN, CFNP, Cm, vice president of clinical services for HealthSource/Hudson Health Plan.
HealthSource is a not-for-profit managed care organization of 37,000 members covered under Medicaid, Child Health Plus, and Family Health Plus. The company was one of the first prepaid health services that came into play under a waiver allowing Medicaid managed care.
When Leonard and her staff examined the reports coming from the state and compared utilization visits and costs, they realized that HealthSource was above the statewide average for utilization for substance abuse and other mental health visits.
"We questioned why it was happening and — if we were doing case management — if we were just authorizing the care and not actually managing the care and getting a better understanding of why the visits were needed," she says.
That’s when they began looking at ways to manage the care of their mental health clients.
"We were well known for our mental health outreach and for the care and referrals we were doing for mental health patients, but we weren’t looking at any utilization data at all. HealthSource was really known as the gold card for mental health services," Leonard says.
After looking at a number of options, the company contracted with Boston-based Beacon Health Strategies to handle the case management and utilization review for its Medicaid managed care mental health services.
"We interviewed vendors and chose one that had the same philosophy and mission as we had and which shared our core values," Leonard says.
The impetus for the new system was not to reduce utilization but to find out why the patients were getting so many more visits than patients covered by other Medicaid managed care plans.
"We have reduced utilization while maintaining and exceeding our reputation in the mental health community," Leonard says.
HealthSource pays Beacon Health Strategies an administration fee for handling case management and utilization review.
"It’s not a risk contract. We didn’t want for our utilization to be managed with a profit-drive force behind it. We were looking for outcomes," she says.
Beacon set up an office on-site at HealthSource/ Hudson Health Plan, hired existing staff, and brought in a new supervisor for the mental health department.
"Being on site helped us tremendously with interaction. We don’t interact telephonically. Our medical case managers and mental health care managers can walk over and discuss a patient," she says.
The case managers who handle the Medicaid patient’s medical care are employed by HealthSource. The mental health case managers are employed by the contractor, Beacon Health Strategies of Boston, but are physically located at HealthSource.
The two entities have arranged to share their databases so the nurses have access but with confidentiality issues covered.
"All case managers can view the patients’ mental health status and access to care as well as physical health care," she adds.
The partners created an internal referral system so that patients who need the services of both the physical health and mental health providers can get the care they need.
For instance, if the mental health people have a patient who is a substance abuser, an alcoholic, a heavy smoker, or suffering from depression and they find out she’s pregnant, they refer her to the medical side and discuss her case with the maternity care case managers.
"In the same way, we may look at a patient and realize that something isn’t happening that needs to happen and refer them over to mental health people," Leonard says.
"Through the right channels of confidentiality, we can collaborate to get a health outcome for the patient," she says.
The plan’s biggest challenge came in 1999, when Medicaid recipients who receive social security benefits had to choose a managed care plan.
The people covered under the mandate are those who receive social security benefits because a disability prevents them from working.
HealthSource’s mandatory SSI enrollees are enrolled for medical benefits, but their mental health benefits are carved out and the services they get are being billed to Medicaid directly. HealthSource is reimbursed for those members’ medical health costs at a capitated per-member per-month rate.
For mental health services, the clients take their Medicaid card to the provider of their choosing. The provider bills the state directly under Medicaid’s fee for service.
"We know that at least 40% of them have a mental health diagnosis that makes them eligible for this benefit. We felt that we needed to do some kind of management on the mental health side, even though we are not paying for it or being reimbursed by the state," Leonard says.
Often, clients with mental problems exacerbate their physical health problems because of substance abuse or because their mental state makes it difficult for them to cope with the challenges of seeking care.
"The challenge is that we pay for their medical health, and a lot of time their medical health is impacted greatly by their mental health but we are out of the loop. We can’t tell them not to go to a certain mental health provider because it’s not in the network. But if they are in our case management system and we can find out where they are going for care, we can help coordinate their care even if we aren’t paying for it," Leonard says
Because HealthSource has mental health case managers on site, it is able to identify the people who needed mental health referrals and work with the community resources that could provide help.
"Preventative care is the biggest challenge in this population where services are being carved out, but we are still responsible for the whole person. People who need care often can’t handle the pressure for getting care," Leonard says.
HealthSource’s internal system helps the case managers connect people to the right system, and the organization’s rapport with providers in the community helps them coordinate care with their medical case management clients who seek mental health services.
"Because we have a relationship with providers, they will notify us when someone is getting services, even though we’re not paying for it," she says.
Six ways to coordinate your mental, medical services
- If you decide to choose a vendor for your mental health case management, make sure the vendor’s philosophy is the same as yours.
- Understand the benefits and challenges of any kind of partnership.
- Realize that you are going to have to make an investment of time and money in the endeavor.
- Set up a way to share information between the two entities.
- Make sure your information technology staff are involved to ensure that patient confidentiality is protected.
- Track and analyze your utilization data.
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