Handout 1

NADD Pre Conference Workshop
The Transition to Managed Care:
Learning from National Experiences
November 12, 2014
1:30 to 4:45 PM
This Pre Conference Workshop addresses the
recent NADD Public Policy Position Statement
and its focus on understanding the nation’s
growing use of pubic and private managed care
services to meet the needs of individuals across
all age groups who have a developmental
disability and co-occurring mental disorder
(psychiatric and/or substance use).
Before We Get Started
Who’s here?
Your questions or topics of particular interest?
• Diane Jacobstein, PhD
Clinical Psychologist/Senior Policy Associate
Georgetown National TA Center for Children’s
Mental Health, Washington, DC
NADD Public Policy Position Statement:
• Eileen Elias, MEd
Disability Services Center Director, JBS International,
North Bethesda, MD
Provider Perspective & Lessons Learned:
• Terry McNelis, MPA, Senior Vice President & Corporate
Director of ID/D Services, NHS Human Services,
Philadelphia, PA
Presenters continued
Administrative Services Organization (ASO) Role &
Lessons Learned in Managing a State’s Service System:
• Kathleen Enerlich, MA, Executive Director
PerformCare, New Jersey
Private Managed Care and Lessons Learned in
Managing a State’s Service System:
• Christina Carter, MSW, Chief Operating Officer,
Smoky Mountain Managed Care Organization,
Asheville, NC
Important Issues for this Population
• Extremely diverse
• MH issues often misunderstood, diagnostic
• Medical issues often precipitate crises
• Overuse of medication, side effects
• Poor match between person and environmental
• High incidence of trauma, often overlooked
• Risk for institutionalization, incarceration,
Stress for families can be unrelenting
• Long and painful searches for services
• Many people do not receive appropriate treatment
• Often involved with multiple systems, poorly
• Families may stay home, become isolated
• Secondary MH issues for parents, siblings
• Custody relinquishment (and divorce) sometimes
a requirement to access public services
Important Services- Often Hard to Find
• Comprehensive evaluation
• Disability-specific expertise at the clinical and
programmatic level
• Expanded service array including respite,
occupational therapy, alternative
• Preventative supports instead of symptom
• Effective crisis prevention
New Georgetown National TA Center Resource:
Effective Strategies Checklist: Children and Youth with
Developmental Disorders and Challenging Behavior
 http://gucchdtacenter.georgetown.edu/publications/Effect
Guiding Values and Principles
based on Stroul, Blau & Friedman, 2010*
Family/consumer-driven (Self-determination)
Youth- guided
Developmentally appropriate (and
developmentally evolving)
* http://gucchdgeorgetown.net/data/documents/SOC_Brief2010.pdf
• Culturally and linguistically competent
• Using evidence-informed and promising
• Integrated care coordination such as
Wraparound or START coordination
• Least restrictive, most normative
• Integrated at the system level
Pre Conference Meeting Goal
Ensure that persons with co-occurring
Intellectual/Developmental Disabilities (IDD)
and mental illness receive the quality of care
necessary for successful community based
living. This involves areas such as long term
supports, behavioral health, as well as physical
health care.
Educational Objectives
Objective One: Understand why individuals with
developmental disabilities and co-occurring mental
illness must be addressed as a core constituency
and not a special population group.
Objective Two: Understand why and how state IDD
and Mental Health authorities are increasingly
relying on public and private managed care to
stretch available dollars, coordinate services, and
document outcomes.
Educational Objectives
Objective Three: Understand the lessons learned
and challenges faced by a private managed care
organization charged to administer and coordinate
systems of care for individuals with developmental
disabilities and co-occurring mental illness.
Objective Four: Understand the stakeholder role
and that of NADD in guiding the development of
managed care to assure adequacy of communitybased services for individuals with developmental
disabilities and co-occurring mental illness.
NADD Public Policy Position Statement
Eileen Elias, MED
Director Disability Services Center
JBS International
NADD Public Policy Committee Chairperson
NADD Public Policy Position Statement
• NADD’s Public Policy Position Paper titled
“Including Individuals with
Intellectual/Developmental Disabilities and CoOccurring Mental Illness: Challenges that Must
Be Addressed in Health Care Reform”
• Located at (http://thenadd.org/about-nadd/naddposition-papers/).
• Over thirty organizations officially endorsed the
NADD Public Policy Position Paper.
NADD Public Policy Statement
In order to advance the Public Policy Statement, NADD held a
Strategic Planning Meeting on October 20, 2014 including
high level representatives from the following organizations:
(1) family members; (2) non-profit disability association
executives; (3) federal government including the Center for
Medicaid and Medicare Services (CMS), SAMHSA, and
Administration for Community Living (ACL); (4) 3rd party
insurers and managed care organizations (MCOs); (5) NADD
Public Policy Committee members; (5) service providers; and
(6) other pertinent stakeholders from both the public and
private sectors.
Policy Statement Overview
• The nation’s response to the service needs of
individuals of all ages with co-occurring IDD (e.g.,
autism) and mental illness (MI) is of concern.
• Nationally, State IDD and mental health (MH)
authorities are responsible for funding and monitoring
needed services, yet support and funding is uneven.
• An increasing number of publicly funded programs are
hard pressed to provide the levels of assistance, therapy,
primary care, long-term medical oversight and
individualized supports that people with these cooccurring conditions need to live, work, and lead
regular lives in the community.
Prevalence of IDD/MI
It is important to recognize that this group makes
up approximately one-third (32.9%) of the total
number of individuals with IDD served by state
developmental disability (DD) agencies
The National Core Indicators data document the
stability of this rate over time.
Prevalence of IDD/MI
Service Challenges
• Improvements in services for people with IDD/MI have been achieved
by many states during the past decade by expanding supports furnished
under the CMS Home & Community-Based Medicaid Waiver programs
and state funding of improved crisis services and increased access to
mental health services.
• While advances have been made, state DD and MH authorities and
service systems continue to struggle to provide effective and appropriate
treatments and supports on a consistent and comprehensive basis.
• State efforts to establish and maintain coordinated systems of care for
people with these co-occurring conditions have been significantly
hampered by administrative and funding barriers that diffuse
responsibilities and by the limited use of best practice models.
• Dramatic declines in state revenues coupled with personnel reductions
and a faltering economic recovery, have eroded the capacity of state
agencies to maintain services. In many areas waiting lists have grown and
access to needed supports are delayed, deferred, or discontinued.
State Actions
Several states and private providers are looking for ways to stretch funding by
coordinating services and improving support outcomes using:
– Home and community-based services under the Section 1915(c) Medicaid
waiver program and the 1915(i) state plan option.
– Self-directed personal care through the new 1915(j) state plan services or using
the 1915(k) Community First Choice personal care option to assist individuals
with living in their homes.
– Federal programs such as Money Follows the Person (MFP) and the Balancing
Incentive Payment (BIP) programs, which provide increased federal financing
to states moving people from institutions to home and community-based
– New federal strategy, the Health Home, to improve the coordination of
primary, acute, behavioral health, and long-term services and supports for
individuals with two or more chronic conditions.
State Actions
• Some states are pursuing managed care as one of several strategies
to decrease expenditures and improve service coordination.
• Managed care approaches have been used to organize the delivery of
acute health care and behavioral health services for some time.
• The application of this model to long-term supports including
Medicaid waiver-based programs furnished to people with IDD is
• At this time, Arizona, Michigan, North Carolina, and Wisconsin
operate managed long-term care for persons with IDD including people
with IDD and co-occurring MI. Kansas is moving the IDD population
into managed care, and Louisiana and several others states are
considering similar moves.
• Persons with IDD may receive mental health services through
managed mental health programs such as Health Homes.
Manage Care Implications
• Managed care proponents state that the approach offers
benefits to states:
– Enables policymakers to more closely align program
expenditures with treatment and service outcomes
– Improves administrative and operational efficiencies
– Reduces costs over time.
• Changing the structure and functioning of state IDD and MH
service systems to adopt to either public or privately administered
managed care is a complex undertaking.
Managed Care Implications
• The National Council on Disabilities’ recent report underscores the
importance of the state’s role in managing Medicaid service delivery if the
plans are operated by states, other public agencies, county governments,
nonprofit organizations, or for-profit corporations.
– The authors recommend that states retain staff with knowledge and
expertise of disability services including community long-term services
and supports, provide effective management and oversight and ensure high
quality of care through MCO contracts and obligations.
– The authors identify 24 policy-related issues and offer several
recommendations for both federal and state policymakers.
Managed Care Implications
• Managed care systems are designed to reduce expenses while
maintaining quality and improving outcomes.
• Service costs and utilization are controlled through highly
structured contracts among the state as the purchaser, the health
plan(s), and the service providers.
• Contracts between the state agency and the MCOs should
specify funding mechanisms, service delivery arrangements, and
the nature of the relationships of the various parties.
Managed Care Implications
• Specific contract provisions are implemented through separate but related
administrative protocols described in operations and policy manuals.
– Written by the state, these documents should identify MCO obligations
with respect to the to be purchased and provided services and supports.
– States must clearly identify the nature and scope of services to be furnished
to people with co-occurring disabilities including service coordination,
provider qualifications, oversight, quality management, cost-effectiveness,
and steps to ensure coordinated care occurs among state agencies,
providers, and others.
MCOs and States Attention re
Individuals with IDD and Co-Occurring MI
• People with co-occurring needs are very
heterogeneous, and their support needs change over
their lifetime.
• Individuals with IDD and co-occurring MI require
a flexible array of services to help them effectively
reside in the community.
• States’ managed care funding models need to be
designed to promote this flexibility and to support
providers’ ability to structure services around the
needs of the individual – children and adults.
Strategic Planning Recommendations
1. Community Living
2. Knowledge and Expertise
3. Person-Centered Services
4. Workforce Competencies and Training
5. Readiness
6. Review Funding
7. Support for Families
8. Inter-Systems Service Coordination
9. Specifications in State Contracts with MCOs
10.Specifications for Public and Private Insurance Benefits and State
Contracts with MCOs
11.Support to Develop Proven Models of Care and Treatment
Provider Perspective
Lessons Learned
One Individual at a Time
Terrence McNelis, MPA
Executive Vice President
NHS Human Services
Who is NHS Human Services
• Large Not for Profit Multi-Service Organization
• Located in 8 States
New York
New Jersey
• Services Provided
 IDD Services
 Adult Behavioral Health
Children’s Services
Confidential - NHS Human Services - Not for Reproduction
Intellectual & Developmental
Disabilities Services
• Located in 4 States
▫ PA, NJ, DE, VA
• Residential Settings
▫ Group Homes, Shared Living, Supported Living,
Independent Living
• Employment, Day and Vocational Programs
▫ Community Integrated Employment, Community
Day Programs, In Home Supports
• Specialized Services
▫ Behavior Specialists, Dual Diagnosis Treatment Team
Confidential - NHS Human Services - Not for Reproduction
Lessons Learned
• NHS has a history of moving challenging people
out of State Centers
• Stand alone Group Homes or Supported Living
• Staff Turnover
• Staff Support
Confidential - NHS Human Services - Not for Reproduction
Environmental Scan
• Limited Dollars available
• Fractured System
• Increased Challenges in Serving Persons w/ ID
and MI.
• 33% of 1% Considered “Boutique” Population
Confidential - NHS Human Services - Not for Reproduction
Essential Ingredients
• Transparency and Communication among all
Stake Holders
Individual Served
Case Management
IDD Provider
Mental Health Provider
Primary Care Provider
Other Stakeholders
Stable DSP work force is essential
• Stable DSP Workforce
• Defined Outcomes and Expectations
• Flexibility in the Payment Options
Confidential - NHS Human Services - Not for Reproduction
Things we have learned
• The better the knowledge of Dual Diagnosis the
better the yield
• NHS is having NADD Certification and
Accreditation of its DDT Teams
• ISP contains efforts to treat MI
• External Supports such as START or DDT Team
• Cutting Costs up front = Greater Costs Later
Confidential - NHS Human Services - Not for Reproduction
• Working with MH Providers and Primary care
facilities that are trained in Dual Diagnosis
• Pay Per Month or case rate versus FFS
• Knowledgeable MCO in Dual Diagnosis
• Flexibility at the payer level
Confidential - NHS Human Services - Not for Reproduction
Administrative Service Organization (ASO) Role and
Lessons Learned in Managing a State’s Service System
Kathy Enerlich, Executive Director
Challenges of rapid, large-scale system
transformation impacting leadership, the
provider community and families.
Lessons learned and strategies for system
of care integration for individuals with
developmental disabilities and cooccurring mental illness.
Quick Look - Who We Are
PerformCare is a full-service managed behavioral health care
organization (MBHO) that supports individuals and providers
through programs in both the public and private sectors.
Founded in 1994 by a group of leading behavioral health providers,
PerformCare is a member of the AmeriHealth Caritas Family of
Companies, one of the largest Medicaid managed care organizations
in the United States.
PerformCare is NCQA Accredited.
PerformCare NJ
As the Administrative Service Organization (ASO) for the State of
New Jersey's Division of Children's System of Care (CSOC) since 2009,
PerformCare New Jersey utilizes significant expertise and integrated
technologies to register, authorize, and coordinate services for
children, youth, and young adults who are experiencing emotional
and behavioral challenges, are developmentally and intellectually
disabled or need certain substance use treatment services.
Who is integrated?
The NJ Children’s System of Care serves:
Behavioral health: Youth with moderate to severe needs, entire NJ
population (over 45,000 youth in the last fiscal year).
Child welfare: Youth with child welfare involvement and a treatment
Developmental disabilities: Youth eligible for services based on
regulatory definition of functional impairment (over 17,000 youth).
Substance use: Youth who are underinsured and have a treatment need
Housing: Young adults experiencing homelessness (573).
Historical Perspective*
July 2012
NJ wins a federal system of
care grant that allowed NJ to
develop a system of care.
NJ restructures the
funding system that
serves children.
Through Medicaid and
the contracted system
administrator, children
no longer need to enter
the child welfare
system to receive
behavioral health care
The Department of
Children and Families
(DCF) becomes the first
cabinet-level department
exclusively dedicated to
children and families
[P.L. 2006, Chapter 47].
disability (I/DD) services for
youth and young adults
under age 21 is
transitioned from the
Department of Human
Services (DHS) Division of
Developmental Disabilities
to the DCF Children’s
System of Care (CSOC).
July 2013
Substance use treatment
services for youth under
age 18 is transitioned
from DHS, Division of
Mental Health and
Addiction Services, to
Closed State
For Children
2007 – 2012
May 2013
The number of youth in
out-of-state behavioral
health care goes from
more than 300 to three.*
Unification of care
management, under
is completed statewide.
Health Home
*How did NJ do this? Careful individualized planning and the development of
in-state options (based on research about what kids need) using resources that were
previously going out of state.
*Source-State of NJ Division of Children’s System of Care PowerPoint
System Foundation
Child Centered & Family Driven
Community Based
Culturally Competent
Outcome Based
Needs Driven
Strengths Based
Family Involvement
Unconditional Care
Home, School &
Community Based
Cost Effective
Team Based
System of Care Vision*
To help youth succeed…
At home
Successfully living with their families and reducing the need for
out-of-home treatment settings.
At school
Successfully attending the least restrictive and most appropriate
school setting close to home.
In the community
Successfully participating in the community and becoming
independent, productive and law-abiding citizens.
*Source: NJ Division of Children’s System of Care slide
The ASO’s Role as a Partner with the State
Vision/policy for system of care
Access to Care: 24/7/365 single point of contact for
Setting data collection priorities
Developing/enhancing electronic medical record
Using data to refine service array
Data collection, reporting and trending
Contract management and service line manager
Provider training, communication, technical
Rate setting, new services (via notice of funds
availability), funding priorities
Leverage braided and blended funding streams to
maximize services and availability of Federal
Funding Participation (FFP)
Defining new service and population rules,
Rapidly implementation ensuring capacity for new
requirements, and criteria, ensuring compliance with services/populations
statutes and regulations
Reasons for Integration of Developmental Disability Services*
“Synchronized service coordination and elimination of duplicate
Support sustainable communities and balanced resource
Bring all children’s services into a single department.
Further current progress and achievement of strategic objectives of
the Department of Children and Families.”
Source: NJ Division of Children’s System of Care slide
State Leadership Challenges
How do you handle uncertainty, ambiguity and rapid change?
Workforce competencies
Reexamination of service models: not merely managing but transformation treatment.
Shifting certain responsibility from a state entity to ASO.
Policy makers faced with no new dollars
Building an accountable oversight structure
Building a fair, equitable service model to access services based on
level of need.
State Leadership Strategies
Understand and communicate the vision of where you are going.
Recall the vision when things get murky.
Be transparent to all system partners - families, providers, staff and state,
giving current status and acknowledging challenges.
Provide comprehensive training to system providers perhaps through a
university contract.
Share and report progress regularly.
Develop partnerships with family, and with advocacy and provider groups
and organizations.
Be flexible and acknowledge what you don’t know yet.
Know who is responsible for what messaging.
Provider Challenges
Looking to a new entity for solutions (ASO)
How can you organization provide greater value?
(strength-based treatment, access to care, quality standards,
outcomes and cost effectiveness)
Processes for budgeting and monitoring of revenues
Use or interact with a new IT platform (foundation for data
Provide improved access
Provider Strategies
Accountable oversight structure that defines and monitors:
• Organization’s role and position in the market.
• Staff productivity
• Documentation and treatment planning – and progress against
identified goals (quality standards)
• Standardize process for client flow from initial request
• Project revenues, deficiencies, surplus, break-even
• Understand program utilization and if you are meeting utilization
benchmarks – data driven performance.
Data Challenges
Agreeing up front on what really matters.
Common definitions are needed to crosswalk definitions and data
Technical questions: how do we get the file?
Privacy concerns: who owns the data, and what can be seen or
Setting priorities for “Day 1” reports.
Data Strategies
Get the right people in the room: content experts, decision makers
(all sides), data analysts and IT.
Recognize that “the perfect is the enemy of the good.” Having
some kind of data decision points early is critical – then fine tune.
Need for specialized data collection: expanded modules for CANS
tools, Level of Care Indicator (LOCI) and custom family support
Build reporting functions to capture discrete data for service
penetration and utilization, and track braided funding of unique
youth populations.
Family Engagement
Address system change and worries early on with families
• Behavioral health: will the system forget about us?
• Developmental disabilities: do you really understand what we need?
• Substance abuse: will it be more difficult to access services?
Establish stakeholder groups
• State-stakeholder group.
• ASO-family leader group.
Be in front of families frequently
Where are we now?
Intellectual and developmental disabilities with dual mental health
diagnoses 1915(c)-like pilot program
The primary goal of the DD/MI program is to provide a safe, stable and
therapeutically supportive environment in the community for children and
young adults with significantly challenging behavior needs.
• ensure the safety of the child or young adult and all participating staff
by providing individual specific training and on- site technical supports;
• decrease elopement risk and safeguard the environment by providing
one-time funds to ensure safety;
• keep families united by placing the child or young adult in close
proximity to the individual’s family or guardian in the least restrictive
• reunite the child or young adult with the family whenever possible
New Services for DD/MI Youth
Under the Pilot the DD/MI youth can receive these new services:
Case/Care Management
Individual Supports
Natural Support Training
Intensive In-Community (II-C) Habilitation
Non-Medical Transportation
Interpreter Services
Intensive In-Home Services
Intensive In-Home (IIH) services specifically Behavioral Interventions
and Clinical Therapeutics were designed and are being implemented.
Our role in the design impacted the treatment plan - allows users to
input clinical information such as the youth’s Needs and Strengths,
as well as Strategies, Techniques and Barriers to treatment. The user
can see all the associated information at once.
Optimally Managed Through Innovative Solutions
Family Support Services Application - ensures resources are
prioritized to families with greatest needs.
Family Portal - electronic eligibility application reduces family
burden and increases operational efficiencies.
DD Eligibility Average Decision Time - Reduced from 195 days to 49
days with improved information for families through clinical and
administrative processes.
Restructured Electronic Record & Consent Process - for exchange of
substance abuse information in compliance with 42 CFR-Part 2.
Assessing Family Support Service Needs (Respite)
Use of a standard tool that:
Assesses capability of the family to care for the youth
Identifies special needs of the youth requiring care
Considers individual family factors
Family Support Services Application for DD Eligible Youth
Single point of access for Family Support Services that consist
primarily of respite services & assistive technology.
Assesses the caregiver’s ability to support the youth in the
Scored based upon severity of needs of the youth, caregiver, and
Challenged to increase the number of families receiving FSS and
number of new families without increasing costs.
Family Support Services Summary of Aggregate Assessments
From January 1 to September 30, 2014 a total of N=3,358 FSS applications for
services were received.
DD/ID Youth Authorized Mobile Response
23% - diagnoses with moderate-severe medical disability
57% - had a prior MRSS dispatch within prior 12 months
83% - caretakers reported aggression requiring Mobile Response
50% - families cited school or afterschool difficulties as main
Outcome of Mobile Response
100% resulted in de-escalation of harmful, disruptive behaviors
Families reported services were helpful & beneficial
Families became aware of other resources & how to access them
Mobile Response consistently made collateral contacts with youth’s
treating providers or agencies involved to communicate needs &
coordinate service delivery
60% referred to the Care Management Organization for ongoing care
Expanding Services While Keeping Down Costs
As youth with Intellectual/Developmental Disabilities were added to the population served by
PerformCare, we linked them to needed family support services without raising costs – providing more
efficiency to the system, and better distributing care.
In 2014 PerformCare
estimates that some
10,000 BH services will
be authorized for DD
DD Youth with BH Services
Cost Per Youth
Dual Diagnosis and the
Managed Care System
Presented by: Christina Carter, MSW
Chief Operating Officer
Smoky Mountain LME/MCO
November 2014
Toll-free access to services: 1-800-849-6127 / N.C. Relay 711
Updated 11/ 2014
What is Smoky Mountain LME/MCO?
In North Carolina, local management entities/managed care
organizations (LME/MCOs) manage:
Medicaid funds
State funds
Local funds
For services related to:
Mental health
Substance Use
Smoky is …
A public entity that operates like a private
company for a public purpose
Similar to public hospitals and public universities
What is Smoky Mountain LME/MCO?
• A public organization, responsive to community needs, that
manages high-quality prevention, treatment and support services
• Services are delivered by network of over 700 private providers
who contract with Smoky
• Smoky manages services in 23 counties and geographically is the
largest public MCO in North Carolina
• 167,180+ MH/IDD/SU on the 1915 (b) (c) Waiver
N.C. Statewide Waiver Expansion
• The waiver allows for public managed care of Medicaid services,
capitated model as opposed to fee-for-service.
• Role for LMEs ensured a local presence and responsiveness to
unique community needs through the public management of
• Smoky went “live” as a Medicaid waiver site in July 2012.
Values & Principles
Person Centered Practices
System of Care
Self Determination
Self- Direction
• Principles to balance clinical & financial
• Core values evidence based practices
History Reflection--Thomas S
• 1990-1998 North Carolina vs Thomas S.
• Class Action Lawsuit brought on behalf of
dually diagnosed adults whose institutional
care did not protect their constitutional rights
• Thomas S. brought suit against NC for alleged
mistreatment & lack of appropriate treatment
for his developmental disability during his
stays at the state psychiatric hospital
Thomas S Class Members:
Complicated clinical needs
Multiple medical needs
Lack of coordinated treatment options
Secluded and mechanically restrained
No behavioral interventions
Overuse of medications without oversight
Ignored community placement options
Lessons Learned
• Complex challenges for providing integrated
community based services
• Best Collaboratives Practices:
– Be clear & stay true to a set of Mission & Values
– Clinical treatment and adaptations of EBP’s
– Single Portal of Entry ( ensure match/choice)
– Interagency Councils ( DSS, EDs, Providers, etc.)
– Special Linkages
– Leadership
Current Understanding
• Smoky prevalence rate accurately reflects data from National
Core Indicators ( 35%)
• Lack of knowledge exists at all levels of care concerning
diagnosis and treatment of co-occurring disorders
• Providers have “fears” about supporting people with cooccurring disorders resulting in gaps in services
• Whole system of care needs to be addressed
• Individuals with co-occurring have a significantly higher rate
of ED admissions
Training and Expertise
• Lack of Experts to train
o School psychologists and teachers
o Parents / Families
o Agency staff – Social Services, DJJ, Health Depts.
o Provider staff – Leaders, Clinical, Supervisors (QP), Direct Support
• Accurate Differential Diagnosis
• Person Centered Plans into placement into either Behavior or Learning track
• Lack of knowledge of Evidence Based Practices for IDD and co-occurrence
• Over 50% of the kids in psychiatric residential treatment facilities (PRTF)
have a co-occurring disorder yet there is not a program that specializes.
• These kids frequently have the longest length of stay due to lack of
treatment and placement options.
• A majority of current placements are either IDD or MH and do not
support co-occurrence.
• There is a lack of adequately trained staff at all levels of care.
Continued System Gaps
• Institutions (PRTF, ICF) may have specialized programs for
Autism Spectrum, Substance Use or Mental Health challenges
but there is a lack of programs that consider co-occurence
• Community homes (AFL, Group and Supported Living)
o Providers silo still exists
• Health Care Providers
o Lack of coordinated care with psychiatrist and primary care
• Families are involved in family therapy, school systems, and
in-home interventions yet the providers of these services
often do not educate these stakeholders on the distinction of
• Provider staff have referrals almost daily and may have
knowledge in MH, IDD or SA. The topic of co-occurrence is
not identified or understood.
• Provider staff are involved with individuals hands-on almost
daily yet many don’t even know the term co-occurrence.
• Psychological Evaluations that identify IDD and MH contain
recommendations for either/or.
• Co Occurrence is not addressed and this adds to the lack of
understanding with providers and families.
• Provide flexible array of person centered supports including
MH, SU and IDD
• Educate all stakeholders on the prevalence of co-occurrence
and need for whole person care
• Coordinate supports with the medical community including
Emergency Departments
• Increase crisis prevention services
• Develop community supports including housing,
employment, and peer support
• UM & Care Coordination Staff understand diagnosis
and treatment of persons with IDD/MH. Staff are
required demonstrate clinical skills drawn from
psychiatry and neurology that also synthesizes
cultural, sociological and psychological perspectives.
• Provider Network needs to cover all mental health
aspects of diagnosis, treatment, and community
• Provider and MCO staff need to review research reports,
case studies, treatment outcome studies, mental health
policy reports, drug information updates, teaching guides,
clinical assessment tools
• Stay abreast on mental health topics with the aim of tying
research findings to practice.
( Ex. pharmacotherapy, psychotherapeutic techniques,
diagnostic issues, education, mental health policy, and
behavioral interventions, etc)
Advantages of MCO to Consumers & Families
• Access to Care- Across all Aspects
• Quality of Care- Total Transparency
• Cost Effectiveness-Serve More People
Advantages of the MCO to Providers
• Local Authorization and Payment
• Eligible Providers
• Collaboration with Primary & Specialty Care
May 2011
Advantages of the MCO for the Overall System
• Predictable Expenses
– CMS requires both the 1915 (b)/(c) waivers must be cost-neutral
– Can cost no more than the current fee-for-service system
– Goal is to manage cost and control the rate of Medicaid growth
• High Quality Standards
• Accountability
– Local oversight and Network performance
• Validation or performance improvement projects
Thank you!
132 Fair Street, Kingston NY 12401 – www.thenadd.org – (800) 331-5362

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