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CART CAPTIONING ROUGH EDITED COPYPROVIDED BY: SHERRIN PATTI* * * * *This is being provided in a rough-draft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings* * * *>> Good afternoon, and welcome to today's webinar titled improving access to care through medicaid 1115 waivers. Sponsored by SAMHSA and developed under contract by the national association of state mental health program directors and presented by the National Alliance on Mental Illness and the national councils of behavioral health. My name is Kelly and I would like to thank you all for joining us today before we introduce today's presenters, I would like to go over a few housekeeping items. Today's webinar is being recorded. The recording along with the PowerPoint presentations will be sent via email within 35 days to all those who registered however you may download the PowerPoint slides now at your convenience at the top of your screen where it says PowerPoint presentation. Please click on upload file to download the slides. For participants only, audio is being streamed through your computer speakers with no need to connect by phone unless necessary in which case the phone? I'm sorry, the phone number is listed in the note section on your screen. If you are having any technical difficulties during this webinar, please type your comment in the Q and A pod on the right side of your screen. And someone will be able to assist you. Please also type your questions for the presenters in the Q and A pod and at the end of the presentation we will ask as many as we can. At the end of the webinar we ask that you take a few moments to complete a short evaluation to give us feedback. We do not offer credits for our webinars but will send you a letter of attendance upon request. My email address will be available at the top of the screen during the evaluation. I would like to thank SAMHSA for allowing us to share this information with you today and again, thank you for joining us. I will now turn it over to Renee who will introduce one of today's speakers. Renee?>> Thank you, Kelly. One of our speakers today is Jodi Kwarciany, she serves as a manager of mental health policy at the national alliance on mental illness in this role she conducts legislative, regulatory and policy research on federal and state priorities. Previously, Jodi worked at the Fiscal Policy Institute where she led the health care agenda by advocating health care policies benefitting low income residents and helped with research on the center of budget and policy priorities and UnitedHealth groups. She holds master's and a bachelor's of arts in political science I will have Casey present the rest of the presenters.>> Thank you, Renee, next up we have Amy Stern a licensed master's social worker and a graduate of the University of Michigan School of Social Work. Amy has been employed with CNS Healthcare since 2004 and has occupied many roles. She oversees children services, individual placement and support, supported employment, psychosocial rehabilitation clubhouses and the student internships. Amy is an adjunct instructor at the University of Michigan school of social work where she teaches on adults with mental illness and infant and child mental health. Dr.?Michele Reid has held a variety of roles from staff psychiatrist to health mental director. As the chief medical officer Dr.?Reid was involved in the design of the EHR implementation of the medicaid meaningful use and the medicare incentive payment system implementing prescribing for substances and managing the contract. And also an HIV AIDS program invite. Dr.?Reid received her BA in Nashville, Tennessee. Dr.?Reid maintained stable housing which fuelled her passion for those struggling with mental illness. After receiving her master's degree she joined in 2014 providing those services for those with severe and persistent mental illness and substance use disorders. It was here she found the need for behavioral healthcare. And has created protocol. She continue to work towards improving behavioral health care integration and coordination promoting wellness, encouraging the growth and success of students. She promotes stability and recovery. And with that, I will turn it over to Jodi to begin the presentation.>> Thank you so much. So hello, everyone, thank you, all, for joining us today on this important and what I think is a very exciting topic. As Renee mentioned earlier, my name is Jodi Kwarciany and I'm the manager of health policy. Here at our national office in Washington,?D.C. So a few quick things about us if you're not familiar with us. This is the nation's largest grassroots organization dedicated to building better lives and more importantly we are a community within your communities, so we have a state organization and nearly every state and local affiliates in nearly 600 communities. So at NAMI being on our advocacy and public policy team I would like to say my work in a nutshell is about understanding what is happening in the healthcare sphere and what that means for people with mental health conditions what. Can we do to be a force for good whether to advocate for a change or show support when we know good things are happening and what state medicaid programs are doing across the country is definitely a large part of my work and I'll just say if you're someone who is part of our NAMI network know that our team is here to provide you technical assistance on initiatives going on in your state. So I won't bury the lead on our topic today. When mental and physical health care services are brought together we know this can do a world of good for people with health care conditions by improving health care access, improving healthcare costs, I will spend a portion talking about what all of this looks like sort of 60,000 feet up if you will before we hear about some great examples later on from our speakers. So a few quick numbers on just how common mental health conditions are. We know about 1 in 5 adults in the U.S. experience a mental illness each year which amounts to more than 50 million adults or about the size of Texas and Florida combined we know about 1 in 25 adults experience serious mental illness. Nearly 4% of all adults in the U.S. experience a cooccurring substance use disorder and mental illness. Both of those conditions at the same time. Unfortunately, though, just under half of U.S. adults with mental illness receive treatment and the average delay between onset of mental illness and treatment is eleven years. So we spent the last slide talking about how common mental health conditions are overall in and within the U.S. population. But what I think is lesser known and really central to our discussion today is just how common it is for people with mental health conditions to also have a cooccurring or coexisting physical health condition. And in fact, are often more likely to develop certain physical conditions and can experience a shorter life span because of them. So you'll notice sort of a smattering of statistics across the next two slides that really drives home that point. I got a little too excited with the data out there. So taking a look at that bottom figure in particular, we know that the majority of adults with mental health conditions have a cooccurring chronic health condition be that asthma, diabetes, hypertension, et cetera, and at the same time we know it's not uncommon for people with one or more chronic physical health conditions to also have a mental illness. The problem is that our health care system largely fails to integrate mental health care with other services and it really creates gaps where care is needed. So, for example, an individual might be struggling to manage their high blood pressure because they may also be dealing with untreated depression. Or an individual might feel like they can't get their antidepressant dosage just right but it turns out that it's untreated diabetes that's causing some of the side effects that they're experiencing. So altogether, this fragmented system creates a lot of challenges in large part because people have to navigate two separate health care systems which gets really confusing oftentimes discouraging frankly and this in turn produces poor healthcare outcomes and doesn't prioritize people getting that best possible care. So this brings us to the promise of mental health care integration which I generally like to define as the care that results from a practiced team of private care and behavioral clinicians and staff working with patients and families using a systematic and costeffective approach to provide patient centered care for a defined population so that's a whole lot but really, you know, in other words, how can providers work together and work with patients and their families to think about that patient's health comprehensively? And as you'll hear later on, there are many ways to go about this and integrate that physical and mental health care. Treatment services can be offered in the same physical location or colocation or maybe health care providers not located in the same place can use shared treatment plans and electronic health records. There's also a role for the patient there as well. We know when individuals participate and engage in treatment with their health care providers we're much more likely to see sustained engagement and improved outcomes. Some of the benefits of care integration. So, you know, primarily increased access to behavioral health care which we know can be a challenge for so many people. And early intervention. Again, making sure that people get the care they need when they need it. We know that there's improved health outcomes for people with mental illness and/or substance use disorder and certainly improved patient experience. Again, that sustained engagement. We know that this has a promise to reduce overall health care costs because people are more effectively able to manage their conditions and prevent more costly interventions and then certainly a really critical factor for us at NAMI is that care integration helps reduce the stigma of mental illness because it's helping boost access and normalize care. Treating a mental health condition is as normal as having asthma treated or a broken bone. So if care integration is so vital how do we entrench that into our health care systems and is an option for people. And that's where medicaid comes in. So medicaid just as a primer, this is the nation's largest? excuse me, the nation's public health insurance program for people with low incomes and also the nation's largest health insurance program. Medicaid covers over 70 million individuals. It's also the largest payer of mental health and substance use disorder services including a quarter of a million adults with these services. Just to drive that home. Medicaid is the largest payer in the U.S. for mental health and substance use disorder services. Overall medicaid finances nearly a fifth of all personal health care spending in the U.S. providing significant financing for hospitals, community health centers, physicians, nursing homes and jobs in the health care sector and now interestingly medicaid is also a federal state partnership meaning both states and the Federal Government share in the financing of the program as well as the design and as a result variability in medicaid is really the rule rather than the exception so states stability their own eligibility standards, benefits packages, provider policies under these broad guidelines trading 56 different medicaid programs. That's one for each state, territory and the District of Columbia so as the old saying goes on the health policy realm. When you've seen one state's medicaid program you've really just seen one state's medicaid program. Taken altogether we can begin to see why the medicaid program is a great place to start developing better care practices. Not only because it covers so many people and plays such a large role in our health care system but also because there is so much opportunity for state experimentation. And before I launch into that experimentation portion if you're relatively new to the space we at NAMI have plenty of resources on hand to help you understand the program overall and specifically what it means for mental health so while states have enormous flexibility within regulatory guidelines the kind of existing framework if you will there is also an additional resource to medicaid and that allows the federal government and state to agree to ignore the federal statute and regulations and this is called a section 1115 demonstration waiver and, this part of the law basically allows the secretary of the U.S. Department of Health and Human Services or HHS to, you know,?"waive" certain federal requirements so in agreement to avoid those for quite a bit for a different purpose and this is done through demonstration projects that are found by that HHS secretary to assist in promoting the objectives of the medicaid program or what I like to think about, 1115 waiver allows states to make promises in medicaid. And these are an increasingly common option to create and test care integration programs. So, okay, so you've heard the promise of mental and physical health care integration and you want to see that happen in your state. Waiver development begins within state medicaid agencies. You know, they're the ones that are going to gather the data, develop a proposal and submit it to the federal government. And then once it's approved they're going to work with stakeholders on the ground to implement it and monitor it. And notably once these waivers are approved this doesn't last for forever. This isn't a total? a forever waiver so to speak. You're just testing something. It's usually only for a period of a couple years. There has to be evidence that not only the stated goals being achieved but it's not costing the federal government anymore than they would normally be providing to the state so if a waiver does appear to be hitting those marks those it becomes an opportunity for the state to treat the waiver and seek reapproval in the years moving forward. And for medicaid beneficiaries for folks in the program, they are unlikely to know that they are part of a,?"waiver" specific. That's really more of the nittygritty within the state and federal officials but ideally they are going to see that change in how their care is being delivered and it's ultimately their metrics that will help determine whether or not this waiver demonstration is a success that should continue and have that continued waiving of federal laws in medicaid. So I listed in this page, states where NAMI has identified explicit care integration waivers and we'll hear more about Michigan's experience in a moment of note there are plenty of states that may be doing elements of care integration within their medicaid programs but it might be a feature of something else and not a largescale designated effort like these ones listed. So all that is to say this list is really just the beginning. So if this is something you'd like to see in your state's medicaid program where can you begin? How can you get involved? Just to see waivers themselves begin with state medicaid agencies that's really the best place for you to begin as well if you want to be a part of that. So, you know, thing to consider, do you have an existing relationship with anyone in your state's medicaid department? You can consider requesting a meeting with your agency. And this information sharing will not only allow you to press officials on why you'd like to see mental and physical health care integration within your state and medical program but it may be an opportunity for your medicaid or program directors to talk to you about where they may be happening in your state or plans in the future that are underway. And once an 1115 waiver is developed, that state must post that proposal for public comment for a period of about a month to make the public aware of these initiatives but also to seek really important feedback that they can hopefully incorporate before they submit that waiver to the federal government for approval so, again, those, you know, there's a period at the state level where folks are allowed to comment but then it's also going to the federal government for comment as well and in fact, if you're part of our network it's entirely possible that you may have heard from me or someone else on our team bugging you saying, hey, you know, we heard that such and such waiver is going on in your state. Is this something that you're aware of? Is this something that we can help you with? You know, what's the on the ground chatter if anything. Another way to plug in is with your elected officials. Folks in your state legislature about the positive role of medicaid and how a medicaid waiver might improve health care access in your state and I bring that up because in some state legislatures, they actually? it's the legislature that has to act before the state medicaid agency can submit a request to CNS. We certainly see that a lot with medicaid expansion in a couple different states. So in order to get the ball rolling, it was something that started in the state legislatures where, you know, they kind of created the approval for it before a state medicaid agency could go about kind of the process of initiating all of that. And certainly, if you're not sure if your state is one of those places that requires that level of approval NAMI is certainly helpful with that. So in my? so in my closing portion, I know I have thrown quite a bit at you, so feel free to contact me or my team if you're interested in learning more about the research I cited, medicaid overall and a special shoutout to any NAMI state and local affiliates. We will help you through understanding legislative bills, break down weedy topics or how to connect to officials in your state. With that I will pass it onto your next presenters. We are happy to be here today to discuss the medicaid waiver. As mentioned earlier. I am Jennifer shoe maker. I I am here with our chief medical officer and program manager Amy Stern. CNS Healthcare has been on quite a journey to integration. In 1995; our organization was once part of a larger health care system with St. Joseph Mercy. East and west merged forming our former name. And and we became accredited. In the early 2000s, we began our relationship with what is now known at Genoa pharmacy who is now our partner. Beginning the phases of primary and health care integration we were awarded the grant also known as PBHDI through the substance abuse and mental health services administration this grant focused on the improvement care coordination and integration to improve the health outcomes of those we serve. We'll talk a little bit more about this grant in our efforts and successes later on in the presentation. In 2017 we became behavioral health accredited. And in 2018 were awarded our first expansion grant through Samsung. We recently received our expansion in 2020. We now have six locations throughout Oakland and Wayne County and opened early in 2020. It's been a long journey but such a rewarding one and we're looking forward to showing you this. We serve 5,000 individuals. We provide services to children. Adolescents, adults and older adults with severe emotional illness and substance abuse disorders. We believe that mental health is a vital part of one's overall health and wellness for children, adolescents, and their families, adults and older adults. We provide an array of services to meet their needs. On June 21st, 2016, Michigan submitted an 1115 demonstration request. The purpose of this demonstration was to allow Michigan to broaden improvement of residential substance disorder services in the substance use disorder providers and benefit to provide a broader continuing of care for beneficiaries seeking help including withdraw management services. This waiver is expected to expire September 30, 2004. This is providing care. The care model is in accordance with the American Society of Addiction Medicine and Michigan believes this will help with recovery for the population. There are three areas of focus with Michigan's 1115 waiver. And those are physical health and integration and care coordination. The strengthening of the SUD care continuum. In 2016, CCBHC's were included in the strategic area of focus. In 2018, CNS Healthcare became CCBHC and became the supported area of focus in 2020, the state of Michigan truly hopes to become a demonstration state. Michigan operates within a Prepaid Inpatient Health Plan, HIHP system. The state's fund behavioral health systems through a system responsible for providing services. This healthcare is in PIHPs within the state while our service areas are Oakland and Wayne county as a CCBHC we work with anyone regardless of where they live. Becoming a CCBHC helped our area greatly and there's a need within our nation and a state to provide these services. Only 43% of all people living with a mental illness receive treatment in any given year. 113 million Americans live in areas that do not have enough mental health professional to meet the needs of the population and suicide is the second leading cause of death for those between the ages of 1034. 59% of youth with major depression do not receive mental health treatment even among the states with greatest access for youth almost 50% of youth are still not receiving the mental health services they need on average 8% of youth have private insurance that does not cover mental health services as a CCBHC we are fable? able to fill the gap in services. We have nearly 20 million people who need substance use treatment but only 12% receive it and in 2017 there was a nearly 10% increase in overdose deaths. Only approximately 33% of substance use treatment facilities offer medicationassisted treatment. There have been several positive changes with CCBHC including the access to care. CNS can triage phone conversations, our staff can help individuals get appointments with needs quickly. Wait times have decreased significantly as a result of CCBHC hiring. We are able to get people in within ten business days or less. We utilize a just in time scheduling for prescriber appointments. Each individual is given a card with a week to call back to schedule their appointment in a seven day window if the individual does not call back within that week they will get a call from one of our staff to help set up that appointment. This has increased our rate. With COVID19 telehealth appointments were increased and increased our no show rate significantly as a CCBHC evidencebased practice moved from best practice to a requirement. Another key aspect is an array of services. On their journey to wellness individuals with complex, mental and substance use disorders would receive an array of supports. Such as crisis response, care coordination and treatment. As required, CCBHCs provide these coordinated services and supports, including rapid response 24/7 crisis services in a very supportive setting. In addition to CCBHC requirements, CNS Healthcare for many years has provided evidencebased practices including TREM, many peer wellness services, RAP, wellness recovery action plans, path, personal action towards health, family education. Clubhouse which we are very excited to announce our two clubhouses opened as of today and our members are very excited. Individual placements and support and assertive community treatment. As well as integrated dual treatment team. Payment may not be denied for services regardless of ability to pay. Quality CCBHC standardizes quality measures for behavioral health. As all CCBHC grantees are required to submit data and demonstrations in the site have another level of data reported to the state. For example, there are nine measures that we track, monitor and report on. And that's the percent of new individuals with initial evaluation provided in ten business days or less. Adult BMI screening. Tobacco use screening. State intervention and follow up unhealthy alcohol use. Suicide risk assessment for child and adolescents as well as adults with major depressive disorder. Screening for clinical depression and follow up plan for all the individuals we serve and following a standardized measure with the depression and remission at twelve months. As mentioned earlier, we did receive our PBHCI grant in 2015 when we were using the levels of integration using the intate? integrative assessment tool. We were at a level three colocated with a federally qualified health care center and had basic partnerships with them. Throughout our journey, we have updated our EHR throughout this time to accommodate better care coordination, electronic messaging, we established meetings that consisted of members of the treatment team including our pharmacy, prescribers and nurses. We are continuing to work towards level six. But this would be? this would include us establishing one shared record and one treatment plan. Going from a level three basic collaboration onsite to a level five full collaboration, was a huge success for us. CCBHCs around the nation set a new standard of excellence. The main focuses are clinical excellence, environmental readiness, reporting costs, strategic planning, continuous quality improvement, educating and reorganizing and retaining our workforce. To set a new standard of care for the individuals that we serve. As of 2020 CCBHCs have made a significant impact in the lives of individuals. 96% of CCBHCs have had a relationship with law enforcement. 90% work with patients. 9,144 patients were engaged in medicationassisted treatment, 94% reported an increase in the number of patients treated for addiction. 84%? offered treatment. 72% provide services to veterans. 3,000 staff were added across the nation for CCBHCs. 61% decreased patient wait times in the very first year of operation. As you can say, there's a significant disparity. We need more to meet the needs of people in our communities and to improve access to make a larger impact. In 1991, FQHCs were established and in 2015 CCBHCs were established. You can see the significant disparity here with FQHCs having more than 1400 nationwide and as of 2020 only 221 CCBHCs.>> Thank you, Jennifer as part of our CCBHC we were required to do a needs based assessment and part of the barriers to good health for individuals were cost, transportation, the mote occasion to get help and also socialization or isolation was an issue. We looked at the community members and what they said was that the biggest stressors in the past year were financial, mental health, and transportation, they all tied for the first place. Employment was a concern. As was housing, mental and dental care that tied for third place. With the pandemic all of these were worse. Many, many folks are out of work having lost health insurance and also having increased stress and housing stress. Also although we have medicaid expansion in Michigan, nationwide, if you look at what's going on, there are a number of states that do not have the medicaid expanded coverage under the Affordable Care Act, and so you have a significant number of individuals out there without any coverage and the CCBHC allows us to provide services to people who are uninsured, underinsured. As you can see and Jennifer told you earlier that the opioid deaths are substantially up in Michigan from 1999 up to 2018 when there are almost 2600 deaths so we're seeing significant rises in opioid deaths overall and especially the synthetic opioid deaths are going up so there's a great need for treatment. However, the Altarum Institute looked at millions of paid claims data from insurances, and found out that there was a significant prevalence of mental disorders in Michigan. And there was a lot of unmet need. And as you can see, in the chart, that with private insurance about 34% of individuals were not getting care. And really about the same, 32%, for Medicare Advantage. However the medicare fee service that amount of underserved was only about 14% but on the other hand dramatic increase in medicaid with 49% of people being untreated other insurances maybe about 18% but a whopping 6.45% for people who were uninsured. When I first saw the Altarum report at a town hall meeting what shocked me most and I was not prepared for that was that the unmet need for substance use disorder care was worse for mental health care and hence the reason they expanded the 1115 waiver. A whopping 76% of people who are uninsured do not get the substance abuse care they need but even worse those with private insurance those were not getting treated. The best group we had in Michigan was medicare fee for service was 48%. One of the biggest plans or participants for the CCBHC was increase in access to medicationassisted treatment. We started off with a one provider who was able to provide medicationassisted treatment and now every physician, nursepractitioner, clinical nurse specialist and a physician assistant is able to have a sub blocks sewnware and about 167% increase. And part of that was really good in looking at what's going on in with the telehealth that allowed us to use the services. As you're aware we're in the middle of the COVID19 epidemic we rolled and moved from maybe five providers doing telehealth to our entire clinical staff. And in year one we saw about 376 individuals and now about 2600 individuals are about almost a 695% improvement in telehealth. We also have additional services for bilingual services. Also we have training in working with military cultural competence working with the LGBTQ+ community and older adult services and also working with trauma and peer integration services and also suicide awareness and suicide prevention.>> Here you can see our overall health outcomes as a result of the initiatives implemented by treating the full person, the people we serve are getting healthier not only improving their mental health but physical health as well the green areas in the chart are improved outcomes in each area. BMI is always remarkable because 79% of people served their BMI was at risk at baseline and 44% of those individuals improved over time leaving 66% no longer at risk. BMI is tied to an individual's nutrition and activity level so this was an excellent outcome. Blood pressure is another hard area to see movement with over 52% at risk at baseline. 20% improved their blood pressure over time leaving 18% to longer at risk. Hemoglobin results as well. 35% improved. And 5% were no longer at risk in addition to the onsite labs health care had at the colocated site we obtained a waiver to obtain results for A 1C, lipid panel. This helps with immediate education and intervention preventing delays. Breath CO is another area that's tied to tobacco use. Almost 46% of people were at risk and over time 24% decreased their CO measurement with 5% no longer at risk. This is amazing. We saw the health outcomes overall were improved and we continue these measures and interventions today. Due to COVID19 we sent scales, blood pressure cuffs and glucometers to individuals' homes who were identified as high risks. These measurements can be captured and?education provided virtually. >> Community outreach is an essential feature. We have reached over 13,000 people since October 2018 through a combination of outreach events. Our goal is to connect with community to provide information about substance abuse as well as how to act in care. We go to community vendor events, panel presentations and large and small group presentations as well and with COVID19 we are participating in events through Zoom to reach our communities. We are proud to have a nationally award winning antistigma education program. Team members in this program all have their own lived experience of mental illness and substance abuse disorders and they provide community education national limit we work with faith based outreach communities. We have worked diligently to ensure these leaders feel equipped to best guide and refer their community member to the help available to them. We have worked hard to make connections with local law enforcement including the Detroit area. We have provided training and build relationships for those areas we serve. We have provide training to students, teachers, school counselors and administrators. We have also established collaborative partnerships to provide school based therapy services to their students. We always work to focus on organizations that represent underserved communities. This includes Native Americans, children, veterans and the LGBTQ+ community. As part of our integrated services we strive to put services in place to help individuals we serve to achieve the wellness goals they have set. We have robust programming we call Wellness Plus which has provided classes onsite. Healthy cooking and nutrition classes. A dedicated wellness coach as well as evidencebased wellness groups such as WAM, BAP. We launched our vitals are vital campaign with the direct goal to improve higher tension management. We do this by obtaining blood pressure at every appointment with a prescriber. We provide interventions such as using standard protocols, and coordination to help individuals become involved with Wellness Plus programming. They are given a fitness tracker and are eligible for gift cards for improvement. We have an annual flu clinic that provides free screenings and the community at large. Since 2015, we have provided 3,704 vaccines, this includes the flu shot, pneumonia vaccine, hepatitis A, B, TDAP and MMR, in 2018 we began hosting an annual men's health fair this was created in the fact that men are less likely to speak out and access primary and behavioral health care. This is open to individuals we serve. We hold this each year and in 2019 we reached 286 people in our one day event. Participants had the option to receive blood pressure screenings, mobile dental services provided through our partner on community health. Vaccinations including MMR, hepatitis A, shingles, and pneumonia and also free haircuts which are always a very popular attraction. We put on this event thanks to our invaluable collaboration with our community partners. We have been given the opportunity to partner with new agencies throughout our journey. Collaboration multiplies impact so these relationships helped us to have an even greater impact in our community. We have valued the opportunity to work with SAMHSA and the international council through our grant. In addition to partnering with other mental health agencies we have also had the opportunity to build relationships with local schools, hospitals, social service organizations and local law enforcement agencies. We deeply value partnerships and use them strategically to enhance services we are able to provide.>> CMC healthcare has achieved certification for stage three and we've done it with a series of upgrades of records. Our practices have dramatically changed over the last several years and we have been working on the standards, focusing on lowering care in the safety of people who are served. As a result, we have had numerous changes and also monitor the CNS meaningful use objectives which is part of our grant. We have converted to electronic prescribing and right now over 90% of our prescriptions are electronic. We do work with the health information exchange and it has been really great since COVID19 to be getting test results for COVID19 we also get all the transfer records from hospitals and emergency rooms. The only thing is our main partners at Genoa, they do have the HIV exchange but a number of the primary practices that we deal with of the top 50 only three of them actually have it so that's an ongoing work for us. As more and more practices get into the HIV world. Also we have a very robust patient portal where after the appointment people can see their medications, their lab work, they can print them out, take them to their primary care physician and have access to their appointment. And there's also the clinical data exchanges with the center for disease control and particularly with the drug monitoring program with the state of Michigan. We have qualified for merit based incentive payment programs. I will tell you when we started out with this in about 2015 for a couple years we got a negative payment adjustment and then a neutral one and now for the last two years we gotten upward payment adjustments for all those provided by nurse practitioners and physical assistants. This helped with our quality and efficiency through the patient portal and other activities and through our CCBHC and consumer family advocate group we really engage patients in their family and care and as Jenny told you this has improved dramatically with the primary care providers and also our system is set in all HIPAA and privacy and security things are done. We actually did graduate from the Great Lakes Transformation Network. We're one of the first behavioral health providers to have done so and we continue to work with the Altarum institute and we work with the Great Lakes practice transformation network and it assisted us for the quality initiatives of when was to be expected. Our electronic health record has also been helpful in addressing the opioid epidemic every year. There are 1012 people who die of overdoses and it really allowed us to better know what kind of drugs are being prescribed other than what we are prescribing. The surgeon general has certainly said that we should not be prescribing benzodiazepines with opioids and over time we were able to reduce it by about 80%. And when we do write for controlled substances you can't write the prescription unless you review the medication assisted program that is our prescription drug monitoring program, so that's been very important. Also the whole? we've gone to electronic prescribing for electronic substances and it's an interesting process. We had to do this identity proofing where they ask what is your mortgage between this and that, have you borrowed money from Ford motor company for your car and my husband pays the bills and I could not remember. I had to get the information from my husband. We use the app to? we don't use the app, it's? if you want to use the mobile app we actually have an eKEY that you put on your key chain and we have Suboxone registration for all our providers. We do work with the Michigan health administration network. We are able to get all the information available, excuse me, on the health information exchange directly in our EHR and that includes our lab work. Our largest partners are LabCorp, Quest Diagnostics and Saint Joseph Mercy Health System. We are able to electronically create a requisition to order labs. But unless we go to those three websites, we cannot electronically order labs and that we will work on for us to electronically order labs. We have good news for you in Michigan. During the telehealth pandemic house bills, since we did this presentation, just in the last ten days, House bills have passed and they have made permanent some of the rules relate ed to telehealth. The expansion must cover telehealth and it must cover remote and store. We must cover digital monitoring and it includes telephone or audio and visual together. We ramped up in about two weeks, we went from six prescribers using telehealth to 150 staff and we have case managers, peers, support specialists, individual placement and supports. Therapists and prescribers all using telehealth with the program. What have people been saying about this? We have gotten tremendous feedback on the telehealth. One individual who I know, she actually was receiving therapy in the office facetoface and then we had a program through CCBHC where she was able to get therapy in her a home, and she's told me that the therapy services she received initially by telephone and later by audio and visual were just as good as in the office or in her home. Another person told us, she doesn't own a car right now. In the city, we have our office in doesn't have public transportation and she appreciated not having to find a ride to see my doctor. We do offer transportation but still, there are challenges there. People also told us, I like the telehealth because I'm at home and I don't have to get dressed or to drive and a mother told us that not having to worry to find someone to watch her kids, getting a ride. And just focus on talking to her therapist was an excellent relief. We have continued to advocate at the state and local level to expand telehealth care, there are various things going on in Congress and again, there's bipartisan letters to support the extension of mental health telecare and we continue to work with our legislatures to expand telehealth. Earlier Amy told you about our vitals are vital program. Believe it or not in 2016 when we started out we see about a thousand people a year with hypertension. Only 10% of those individuals had their blood pressure controlled. And through this CCBHC and all the various initiatives you heard about, we wound up at the end of 2019, we had improved blood pressure control by 428% and were up to 54% of people with blood pressure control. As you can see, during the year 2020 with COVID19 we back slid. This mostly had to do with the fact that people were not coming in the office or being seen virtually and we were not getting blood pressure. So the CCBHC grant has allowed us as Jenny told you to purchase scales, glucometers, and blood pressure cuffs to individuals can take their blood pressures at home after the nurse teaches them. We have same day appointments inperson. We are now able to get same day appointments with the PCP through telehealth and in fact, just last week they started on a couple days a week seeing people in the office we're also able to offer virtual visits with the office now. For people with chronic diseases and we have virtual nursing and prescribers. Additionally we're working with population health management and through Oakland community health network we have access to CMT's ProAct tool through Relias which is about to be changed to population health with Relias and they have as targeting these measures for improvement. We are looking at adherence to antipsychotic medications. And they are looking for diabetic screening tests during the year and we are able to accomplish that through our onsite lab and our point of service testing. We also have a couple on antidepressant medication management, the initial phase, looking at 84 days of continuous refill of prescriptions at the beginning of treatment and then continuation of maintenance, 180 days of care. Basically, in terms of population, health management, the OCHN also has complex case management and they do messaging, letters and calls to individuals who have not followed up with their PCPs and don't have the lab work, don't have vital signs and again we're promoting same day appointments and also we work all individuals who leave here to go to ER urgent care we have telehealth. And COVID19, on March 17, 80% of our staff went home and services were not provided at home. We had two clubhouses closed for three months. But this allows us flexibility to respond more quickly to the change of conditions. As I told you we only had about five or six providers using the platform it cost us about 200 dollars per license and we are able to get in. And it was 25 dollars per month and we were able to get everybody done. We did continue to have all sites open, the clinical sites but people were on long acting medications, or people with unstable conditions who had to have blood work. We got 150 prescribers, case managers, and employment specialists using the platform. But I would say that for us, securing PPE was a major barrier but we have to really thank the city of Detroit health department. The Oakland County health department for surgical and n95 masks and the Ford Motor Company for providing face shields. We are now able to meet our needs for PPE and thermometers. We are on Amazon every other day trying to find a thermometer was almost impossible in the early part of March but through the CCBHC we have had funding to stock up and thank goodness we got them. The health department called the other day and said do you still need them and we said yes and we got five from them and delivered them to the clubhouses yesterday. And the Michigan health information network is providing our COVID19 testing results when I sent this presentation in there were 306 people who were tested now we're up to 555 today. We have about 30 individuals that are under care with us who are positive and we had 8 hospitalizations and about 5 deaths so far. Criteria for testing has changed in Michigan but still not everybody who is asymptomatic can be eligible but we are getting the results directly in our EHR. COVID19 pandemic has had a huge staff impact. We've implemented the expanded family medical leave act and the emergency paid sick leave and 25 of our 260 staff either had COVID19, been quarantined or had to be home due to child care issues. We have had two hospitalizations of staff but no deaths. Overcoming challenges. We'll all talk about these challenges and I will tell you that recruitment and retention of staff is still an ongoing issue for us. Having the CCBHC funding has allowed us to have a recruiter which has dramatically improved it and we have challenges with the state of Michigan. They do not allow medical assistance or licensed professional nurses to be billable, to do vital signs and assist us so this is the ongoing issue. We talked earlier about the constraining telehealth regulations that we continue to beat those back and also the CCBHC does not provide medication. So we do struggle with that. The FQHCs have that 340B drug program and although we're a generic program again it is an issue trying to be able to fund medication because it can't be paid for with the grant. And also one thing that would be helpful where the FQHCs are on a payment system we are a grant funding and looking forward and hoping that Michigan becomes a demonstration state and that allows us to have the payment to assist us in many of these things.>> As a grant funded CCBHC expansion organization we are required to capture national outcome measures. It is required upon entering services and every six months thereafter. This is lengthy process and there's a manual data entry process which is time sensitive for staff and very lengthy. We've made significant improvements. They are embedded within our EHR. We have chart alerts to complete them and we added automatic recording is available in our system. In addition to the assessment there are mechanical health indicators to be captured on these individuals and be manually entered into the database. We have come a long way but still working through these challenges on a daily basis. The NOMs are unique. The full demonstration site. Unless they have a combination of a grant and are a demonstration site they do not have to complete these NOMs.>> As we have had a chance to enhance these services it means that we need to enhance staff training. We have focused our training efforts in the utilization of evidencebased practices. Zero suicide and as said data entry. Sustainability and advocacy efforts are very important in sustaining and abstaining funding for health care integration, primary and health care integration, we know we've seen successes in the individuals we serve. The outcomes speak for themselves and have improved the mental outcome as well. This community gave us necessary resource to learn from other CCBHCs and strengthen our implementation approaches and integration effort. We're also part of a larger collaboration in the state of Michigan to show that Michigan benefits from this model of care. Debbie herself, or one of her staff is present to provide update to make this permanent across our nation. Collaborating with the Michigan Department of Health and Human Services is vital to the success of this model as we prepare to become a CCBHC demonstration state in the near future hopefully. State officials are working collaboratively with the existing CCBHCs to be able to implement the state demonstration. In December of 2019 leaders of the Senate finance committee reached an agreement on a two year extension in more than doubling the current program by adding 11 additional state to the certified community medicaid program. This was expedited through legislation with the introduction of the CARES Act and they announced 166 awards for certified community behavioral health clinic expansion grants. The grant funding included 200 million in annually appropriated funding in addition to 250 million. As part of this CARES Act, this legislation also expanded the CCBHC project to two additional states. We are hopeful Michigan will be included in the two additional states. And we are currently in preparation for this should that happen. How can you get involved? This is a question that we hear quite frequently when we talk, especially when we participate in learning communities across the nation. The future of CCBHCs in our nation is very? very important. And it's at a very important turning point. It's? obtaining funding to make integration possible is very important. And the existing CCBHC demonstration state funding has been extended thanks to the CARES Act. It's important that this legislation continues to be funded and include more states as a part of this demonstration. It's important to advocate for permanent funding across the nation so we can have a larger impact on our communities. This would mean more organizations would be eligible for the federal rate and to provide services and more opportunity for other organizations. It's important to call your U.S. representative and urge them to support these bills. And with that, we have really enjoyed presenting on our journey to integration and time for questions, we'd be happy to answer them.>> Thank you, everyone for presenting. We will be moderating the Q and A. So I will get started for two questions. For CNS that we received during your presentation. The first was asking for some clarification. Did you say that Michigan's 1115 waiver included expanding access to CCBHCs? How will this be different from the demonstration grant if selected by SAMHSA?>> Could you say that again, I couldn't hear you.>> Did you say that Michigan's? yes. Did you say that Michigan's 1115 waiver included expanding access to CCBHCs? How will this be different from the demonstration grant if selected by SAMHSA?>> Oh, no, the state included as part of the waiver. So there were already nine CCBHCs in the state of Michigan since 2018 so they just roped the expectations into the 1115. We were still awaiting to hear about whether or not Michigan will be a demonstration state.>> Thank you for your clarification. Another question received was asked, are there any ongoing small groups or classes to encourage healthy lifestyles and allow individuals served to support each other?>> Yeah, so during COVID19, it's been very difficult to of course meet in person in groups. We do have a lot of our teams, specific our treatment team to our meeting in parks so they can safely provide access to wellness activities and groups and provide the support that our individuals really need and they've been lacking during this pandemic. Right now that is how they are providing that. So it can be done safely. We also are providing therapy groups through DOXY.ME. We are hoping in the near future to add more wellness groups via telehealth because they are really missing? we're used to having two times a week onsite classes and our individuals are really, really missing that piece and so we're developing creative ways to do that safely now.>> Yeah, we also offer the cooking class with the Michigan State University extension. We have a personal trainer that does exercises. And as we roll out of COVID we'll be back online but we're looking to have more of these things offered virtually and one way we can do that, what we found is that 30% of our the people we serve either don't have a smart phone or enough of a data plan or access to the internet so the one thing we would like to see, the SAMHSA dollars, we can use our county, and our state and SAMHSA dollars to buy cell phones for the staff but not for the people that we serve. So we have really beating the bushes for that. We have applied for a grant to the FCC and were successful for that. One of the biggest barriers for us is the need to get more cell phones. We found some reasonable TracFones for a hundred bucks. We got enough founding for about 50 phones now but there's several hundred people who need phones. That's one of our major missions is to find cell phones.>> With our Wellness Plus program that was an originally funded we're able to expand all of those services and expand them through funding and as Dr.?Reid said once it's safe to do so we plan to resume all of our wellness activities.>> Right. Thank you so much for this. I'll read a couple more questions. Let's see here. How are other states integrating care? I live in Illinois. Can you speak about their response to the 1115 medicated waivers?>> I don't have any specific information about the other states. We're just familiar about the Michigan program. Perhaps somebody at NAMI maybe could answer? >> Yeah, this is Jodi. Happy to comment. It really is, you know, just like medicaid programs overall. You know, if you've seen one waiver you've kind of seen one waiver so absent me commenting on what this kind of looks like from state to state from those we know have applied for, you know, care integration waivers, I would be happy to share with that individual a link to Illinois' application to the Federal Government on their proposal 1115 waiver for care integration. Just to give them a full rundown of what that looks like because the waivers themselves are really lengthy documents that goes through all the nuts and bolts on what that could look like. That waive could look like for the state. So happy to share that afterwards.>> Right. Thank you. And then, another question we have and this is for, you know, any presenter to kind of provide their knowledge on is do these waivers, 1115 waivers have to funnel through SQHC?>> Oh I can answer that in the state of Michigan, no, the SQHCs are on a different level. Their planning is a totally different stream than us. This is not involved with these in Michigan.>> And I'll just add, this is Jodi. So you know an SQHC or really any provider, it's not necessarily that they have to have a very specific stamp of approval but certainly they are very, very involved with the process. Because, you know, a state could create the most beautiful immaculate waiver but if you don't have buy in from the providers it's not going to work. Entities like FQHCs are going to work closely with their state medicaid agencies on any waiver that's going to heavily involve them.>> Thank you. I can take the next couple questions. One question we received is asking how are you able to reach individuals via telehealth that do not have access to a cell phone or computer?>> I think we've been successful at CNS Healthcare in beating the bushes to find some dollars. Genoa Healthcare, our privacy partner their staff contributed money. We got money there. There was an FCC grant for rural health areas. It applied to us. We were able to get those dollars. That was most helpful for us and, again, for CCBHC, the SAMHSA was very clear, you could not use those dollars to pay for it. It was about looking for local foundation support beating the bushes. We applied for another grant. They said they had so many application. One particular grant we were turned down for but really you need to put the technology in the hands of the people. We have been successful with our funding source at OCHN. They purchased about 50 tablets to be put in the specialized residential setting so we worked with about 30 different group homes. They were able to get a laptop or tablet in there. They did find funding those but it's really beating the bushes. We still are not where we need to be. We got about 25 group homes are straight and about 50 people are served. We need hundreds more. We will continue to pursue a funding that will allow us to get phones for people. And a number of people have medicaid and are able to get phones related to that but often they are not cell phones and they do not have enough data plans to support. Wifi is not good enough in their homes. That is an obstacle for us that we will continue to work on.>> One other question we received and this is again for CNS directly asks if you have any evidencebased peer support groups that support healthy living and tobacco recovery?>> Oh, absolutely. We implement a wide array of evidencebased peer read groups and they're widely popular. We have WRAP groups which is wellness recovery action plan. This is with emotional difficulties. Path, personal action towards health. A chronic disease selfmanagement program. To help those with daytoday management of longterm health conditions. Action management which is another peer deliver group. Training program that's designed to increase resiliency and management of their health conditions and smoking cessation groups which are widely popular and learning about choices. And we find our smoking cessation groups are very uniquely ran where they're broken up into two sections. The first six weeks is for just talking about getting ready to quit smoking and the second six weeks is actually setting that goal and working with the peer support to help support you along that. We find that very successful, breaking it up into those two sections. And our peer support, our really vital part of the work that we do even through COVID19 we have seen our peer support really increase significantly because even through all of this, that's the one support person that our individuals really look to for support and their success of their overall mental and physical health.>> And I think the tobacco education, the first part of that is really great because you don't have to be ready to quit. If the course on tobacco education some people may not be ready to quit. Really the personal part is about tobacco education and we're proud of our peers who have been certified by the state of Michigan to provide these evidencebased practices and they go around the state teaching others how to do it so we have master trainers who are working and are proud of the work.>> Absolutely. Can I not second that more.>> Thank you. And I think we have one more question, HHS had been indicated they no longer want to support any new 1115 waivers or extensions. Has that changed? What is the feeling in Washington about the effectiveness of waivers?>> Sure. I can take that. This is Jodi. So Geoff, I feel you and I will have to connect. This is news to me. So I am intrigued to hear more about what you've heard and what HHS is doing. So from, you know, based on my knowledge, I was not aware that HHS has indicated anything like that. We know that, you know, even as recently as January, I want to say it was January was when the administration was rolling out a new kind of 1115 kind of opportunity, an or an HHO through 115. So I can't say whether or not they? that they're not supporting new 1115 waivers or extensions but we know that just overall, waivers are become more common place not only the 1115s that allow for these demonstrations but also throughout the COVID19 pandemic, many, many, states were relying on what are called 1135 waivers which gave emergency authorizations to states as they dealt with the pandemic within their own states. So I think that, again, this is? purely from my vantage point but I think we'll continue to see, you know, waivers moving forward not only 1115 but some of the other ones out there. As states want to continue to experiment within their medicaid programs. And I would actually venture to say that, you know, right now, as states are, you know, they've gone through a lot of those emergency you know, things that they're dealing with and certainly we know that the pandemic is continuing but we have a sense that HHS may be shifting to focus kind of back on some of their daytoday work including reviewing just standard waiver applications. And it's, oh, it looks like we have a comment as well from somebody at CMS which is through the U.S. Department of Health and Human Services.>> Yes. Thank you. The comment for those from CMS the comment was we have not stopped accepting 1115 waivers and I do believe we don't have any upcoming questions. So I'll let Kelly take the lead from here.>> Thank you. And I would like to take this time to thank our presenters for presenting today. Thank you so much for sharing this information with us. And, again, I would like to thank SAMHSA for allowing us to share this information with you. I'm going to switch the screen now to a short evaluation. ................
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