Medicaid Health Home Research Articles

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies’ effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Substance Use Disorders and Diabetes Care: Lessons From New York Health Homes.

Individuals that have both diabetes and substance use disorder (SUD) are more likely to have adverse health outcomes and are less likely to receive high quality diabetes care, compared with patients without coexisting SUD. Care management programs for patients with chronic diseases, such as diabetes and SUD, have been associated with improvements in the process and outcomes of care. The aim was to assess the impact of having coexisting SUD on diabetes process of care metrics. Preintervention/postintervention triple difference analysis. Participants in the New York State Medicaid Health Home (NYS-HH) care management program who have diabetes and a propensity-matched comparison group of nonparticipants (N=37,260). Process of care metrics for patients with diabetes: an eye (retinal) exam, HbA1c test, medical attention (screening laboratory measurements) for nephropathy, and receiving all 3 in the past year. Before enrollment in NYS-HH, individuals with comorbid SUD had fewer claims for eye exams and HbA1c tests compared with those without comorbid SUD. Diabetes process of care improvements associated with NYS-HH enrollment were larger among those with comorbid SUD [eye exam: adjusted odds ratio (AOR)=1.08; 95% confidence interval (CI): 1.01-1.15]; HbA1c test: AOR=1.20 (95% CI: 1.11-1.29); medical attention for nephropathy: AOR=1.21 (95% CI: 1.12-1.31); all 3: AOR=1.09 (95% CI: 1.02-1.16). Individuals with both diabetes and SUD may benefit moderately more from care management than those without comorbid SUD. Individuals with both SUD and diabetes who are not enrolled in care management may be missing out on crucial diabetes care.

Identification and Treatment of Addiction in Medicaid Health Homes.

Coordinated care models, such as the Medicaid health home, may be well positioned to identify and address addiction, yet little is known about the strategies health home plans use to identify and treat this condition. This study examined state requirements of active Medicaid health home plans. Content analyses of all 35 active Medicaid health home plans were conducted to identify state requirements related to enrollment eligibility; provision of addiction screening, treatment, and prevention services; inclusion of addiction treatment professionals within the health home provider care team; and outcomes monitoring. Apart from health homes specifically focused on addiction, few states require health home plans to screen (44% of primary care-based and 33% of psychiatric health homes), treat (0% and 13%, respectively), and monitor treatment services for addiction (25% and 13%, respectively). Limited screening and treatment of addiction within health homes may limit the model's effectiveness in improving overall health.

Capsule Commentary for McGinty et al., Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

Capsule Commentary for McGinty et al., Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness.

Nineteen US states and D.C. have used the Affordable Care Act Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical healthcare management and coordination into specialty mental health programs. No studies have evaluated the effects of a BHH program created through the Affordable Care Act waiver on cardiovascular care quality among people with SMI. To study the effects of Maryland's Medicaid health home waiver BHH program, implemented October 1, 2013, on quality of cardiovascular care among individuals with SMI. Retrospective cohort analysis using Maryland Medicaid administrative claims data from July 1, 2010, to September 30, 2016. We used marginal structural modeling with inverse probability of treatment weighting to account for censoring and potential time-dependent confounding. Maryland Medicaid beneficiaries with diabetes or cardiovascular disease (CVD) participating in psychiatric rehabilitation programs, the setting in which BHHs were implemented. To qualify for psychiatric rehabilitation programs, individuals must have SMI. The analytic sample included BHH and non-BHH participants, N = 2605 with diabetes and N = 1899 with CVD. Healthcare Effectiveness Data and Information Set (HEDIS) measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; HbA1c, diabetic nephropathy, and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD. Relative to non-enrollment, enrollment in Maryland's BHH program was associated with increased likelihood of eye exam receipt among individuals with SMI and co-morbid diabetes, but no changes in other care quality measures. Additional financing, infrastructure, and implementation supports may be needed to realize the full potential of Maryland's BHH to improve cardiovascular care for people with SMI.

The effects of the Maryland Medicaid Health Home Waiver on Emergency Department and inpatient utilization among individuals with serious mental illness

ObjectiveThe Maryland Medicaid health home program, established through the Affordable Care Act's Medicaid health home waiver, integrates primary care services into specialty mental health programs for adults with serious mental illness (SMI). We evaluated the effect of this program on all-cause, physical, and behavioral health emergency department (ED) and inpatient utilization. MethodUsing marginal structural modeling to control for time-invariant and time-varying confounding, we analyzed Medicaid administrative claims data for 12,232 enrollees with SMI from October 1, 2012 to December 31, 2016; 3319 individuals were enrolled in a BHH and 8913 were never enrolled. ResultsHealth home enrollment was associated with reduced probability of all-cause (PP: 0.23 BHH enrollment vs. 0.26 non-enrollment, p < 0.01) and physical health ED visits (PP: 0.21 BHH enrollment vs. 0.24 non-enrollment, p < 0.01) and no effect on inpatient admissions per person-three-month period. ConclusionThese results suggest the Maryland Medicaid health home waiver's focus on supporting physical health care coordination by specialty mental health programs may be preventing ED visits among adults with SMI, although effect sizes are small.

Nursing impact on chronic disease Medicaid health home patients: A qualitative study

Managing individuals with chronic health conditions in the primary care setting continues to be a significant challenge in the US health care system. This issue is further compounded for low-income individuals with both mental health and physical health chronic conditions. The Affordable Care Act provides opportunities to launch chronic disease Medicaid health homes (MHH) to address the existing health care gaps. Within a multidisciplinary team, the nurse serves an integral role as the main care manager and coordinator aimed to improve patient experiences, health outcomes, and lowering health care costs. The aim of this qualitative study is to assess the nurse's perception of their MHH role and how they may impact patient health care utilization patterns. The qualitative study included a focus group of eleven nurses and individual interviews with seven nurses. Six themes were identified that focus on how nurses can use a wide range of effective communication strategies and interpersonal skills to establish and maintain a nurse-patient relationship. The six themes provided insight as to nurses' perceived role in an MHH and how they impact patient health outcomes. The overarching message addressed connecting with the patient and taking the time to find out what was important to them. Nurses were able to impact patient health care utilization patterns.

The Policy Ecology of Behavioral Health Homes: Case Study of Maryland's Medicaid Health Home Program.

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland's Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

Supporting Diabetes Management—Perspectives on Care Management in a Medicaid Health Home in Alabama

Background: Chronic diseases like diabetes require constant and ongoing self-management. The Health Home model provides a unique platform to facilitate diabetes management and connect patients to community resources that support and promote self-management. However, little is known about specific activities, barriers, and needs that exist in Health Homes particularly in Alabama which suffers disparately high rates of diabetes compared to other regions. To address this knowledge gap, the purpose of this study is to understand how a Medicaid Health Home facilitates diabetes management in Alabama. Methods: Three interviewers conducted semi-structured interviews with six staff at a health home organization. A guide facilitated discussion on patient recruitment, frequency and mode of communication with patients and health care delivery team, and clinical and non-clinical patient-related barriers. Content analysis was performed to identify major themes using an iterative, combined deductive and inductive approach. Results: Six female participants were aged a mean 49 years; majority employed 4 to 5 years in current role. Professional qualifications included a dietician, social worker, and nurses. Five care management domains were identified: health education, medication management, nutrition therapy, and addressing psychosocial issues. Facilitators of staff roles discussed were a high degree of collaboration within their organization and externally with providers and other professionals. For example, staff described the value of reciprocal relationships in which providers interacted with the health home. Barriers to care management included state Medicaid cost-sharing policies, medication limits, timely access to care, and variation in the availability of community resources. Conclusions: These findings suggest that opportunities exist to intervene at the policy and healthcare system level to improve adult diabetes management for a vulnerable population. Disclosure A.A. Agne: None. F. Mondesir: None. J.P. Shelley: None. M. Pisu: None. A. Cherrington: Advisory Panel; Self; AstraZeneca. Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Consultant; Self; Novo Nordisk Inc..

Measuring Variation Across Dimensions of Integrated Care: The Maryland Medicaid Health Home Model.

Despite the proliferation of initiatives to integrate services for people with serious mental illness (SMI), measures of distinct dimensions of integration, such as spatial arrangement and care team expertise, are lacking. Such measures are needed to support organizations' assessment of progress toward integrated service delivery. We developed measures characterizing integration of behavioral, somatic, and social services to operationalize the integrated care dimensions conceived by the Agency for Healthcare Research and Quality. In a survey fielded to 46 Maryland Medicaid health homes (response rate: 96%) serving adults with SMI during 2015-2016, we found that these measures provided a useful description of variation across dimensions of integration.

An innovative model to coordinate healthcare and social services for people with serious mental illness: A mixed-methods case study of Maryland's Medicaid health home program.

We conducted a case study examining implementation of Maryland's Medicaid health home program, a unique model for integration of behavioral, somatic, and social services for people with serious mental illness (SMI) in the psychiatric rehabilitation program setting. We conducted interviews and surveys with health home leaders (N=72) and front-line staff (N=627) representing 46 of the 48 total health home programs active during the November 2015-December 2016 study period. We measured the structural and service characteristics of the 46 health home programs and leaders' and staff members' perceptions of program implementation. Health home program structure varied across sites: for example, 15% of programs had co-located primary care providers and 76% had onsite supported employment providers. Most leaders and staff viewed the health home program as having strong organizational fit with psychiatric rehabilitation programs' organizational structures and missions, but noted implementation challenges around health IT, population health management, and coordination with external providers. Maryland's psychiatric rehabilitation-based health home is a promising model for integration of behavioral, somatic, and social services for people with SMI but may be strengthened by additional policy and implementation supports, including incentives for external providers to engage in care coordination with health home providers.

Experiences of three states implementing the Medicaid health home model to address opioid use disorder—Case studies in Maryland, Rhode Island, and Vermont

PurposeThe United States is facing an unprecedented opioid epidemic. The Affordable Care Act (ACA) included several provisions designed to increase care coordination in state Medicaid programs and improve outcomes for those with chronic conditions, including substance use disorders. Three states—Maryland, Rhode Island, and Vermont – adopted the ACA's optional Medicaid health home model for individuals with opioid use disorder. The model coordinates opioid use disorder treatment that features opioid agonist therapy provided at opioid treatment programs (OTPs) and Office-based Opioid Treatment (OBOT) with medical and behavioral health care and other services, including those addressing social determinants of health. This study examines state approaches to opioid health homes (OHH) and uses a retrospective analysis to identify facilitators and barriers to the program's implementation from the perspectives of multiple stakeholders. MethodsWe conducted 28 semi-structured discussions with 70 discussants across the three states, including representatives from state agencies, OHH providers (OTPs and OBOTs), Medicaid health plans, and provider associations. Discussions were recorded, transcribed, and analyzed using NVivo. In addition, we reviewed state health home applications, policies, regulatory guidance, reporting, and other available OHH materials. We adapted the Exploration, Preparation, Implementation, and Sustainment (EPIS) model as a guiding framework to examine the collected data, helping us to identify key factors affecting each stage of the OHH implementation. ResultsOverall, discussants reported that the OHH model was implemented successfully and was responsible for substantial improvements in patient care. Contextual factors at both the state level (e.g., legislation, funding, state leadership, program design) and provider level (OHH provider characteristics, leadership, adaptability) affected each stage of implementation of the OHH model. States took a variety of approaches in designing and implementing the model, with facilitators related to gathering stakeholder input, receiving guidance and technical assistance, and tailoring program design to build on the state's existing care coordination initiatives and provider infrastructure. The OHH model constituted a substantial change for almost all OHH providers in the study, who reported that facilitators to implementation included having goals and workplace culture that were compatible with the OHH model, and having technical support from the state or non-governmental organizations. Some of the main barriers to implementation reported by OHH providers include shortages of primary care providers, dentists, and other providers willing to accept referrals of patients with opioid use disorder; limited community resources to address social determinants of health; challenges related to state-specific program design, such as staffing requirements and reimbursement methodology; care coordination limitations due to confidentiality restrictions and technological barriers; and internal capacity of providers to adopt the new model of care. ConclusionsThe OHH model appears to have the potential to effectively address the complex needs of individuals with opioid use disorder by providing whole-person care that integrates medical care, behavioral health, and social services and supports. The experiences of Maryland, Rhode Island, and Vermont can guide development and implementation of similar OHH initiatives in other states.

Implementing a Health Home: Michigan's Experience.

As the number of individuals in the United States with chronic conditions and the associated costs in caring for these individuals continues to rise, there is a need to transform how health care services are delivered. Under Section 2703 of the Affordable Care Act of 2010, the federal government provides state Medicaid programs the opportunity to improve care coordination for people with chronic conditions in a person-centered approach through the establishment of health homes. Given the complexity of care for Medicaid beneficiaries with chronic conditions, addressing the social determinants of health and providing integrated care are central to effectively improving health outcomes and generating cost-savings. Although launching a health home model is a step toward improving care coordination and care management for high-risk individuals, there are myriad components to implementing such a program. The purpose of this article is to explain the process that Michigan policymakers undertook to implement its Section 2703 Medicaid health home initiative, named the MI Care Team. The authors present lessons learned for policymakers and stakeholders in other states seeking to implement a Medicaid health home and explain how the nursing profession is integral for health homes.

Integrating health care for high-need medicaid beneficiaries with serious mental illness and chronic physical health conditions at managed care, provider, and consumer levels.

Policies supporting value-based care and alternative payment models, notably in the Affordable Care Act and the Medicare Access & CHIP Reauthorization Act of 2015, offer hope to advance care integration for individuals with behavioral and chronic physical health conditions. The potential for integration to improve quality while managing costs for individuals with high needs, coupled with the remaining financial, operational, and policy challenges, underscores a need for continued discussion of integration programs' preliminary outcomes and lessons. The authors describe the early efforts of the HealthChoices HealthConnections pilot program for adult Medicaid beneficiaries with serious mental illness and co-occurring chronic conditions, which used a navigator model in 3 southeastern Pennsylvania counties. The authors conducted a difference-in-differences analysis of emergency department (ED) visits, hospitalizations, and readmissions using Medicaid claims data and collected data about program implementation. ED visits decreased 4% among study group members (n = 4,788) while increasing almost 6% in the comparison group (n = 7,039) during the intervention period (p = .036); there were no statistically significant differences in hospitalizations or readmissions. This pilot demonstrated the promise of nurse navigators (care managers) to bridge gaps between the physical and mental health care systems, and the success of a private-public partnership developing a member profile to share behavioral and physical health information in the absence of an interoperable health information technology system. The implementation lessons can inform state Medicaid Health Home models as well as accountable care organizations considering incorporation of behavioral health care. (PsycINFO Database Record

Medicaid Health Home Reducing Costs and Reliance on Emergency Department; Evidence From Iowa: Shane D, Nguyen-Hoang P, Bentler SE, et al. Medical Care. 2016; 54:752-757

Medicaid Health Home Reducing Costs and Reliance on Emergency Department; Evidence From Iowa: Shane D, Nguyen-Hoang P, Bentler SE, et al. Medical Care. 2016; 54:752-757

Medicaid Health Home Reducing Costs and Reliance on Emergency Department: Evidence From Iowa.

The Affordable Care Act allowed an optional Medicaid State Plan benefit for states to establish Health Homes coordinating care for people who have chronic conditions. Differences in medical home program incentives and implementation styles are important to understand in evaluating effects on key outcomes such as cost and acute care. In Iowa, a Medicaid Health Home (MHH) program was developed targeting Medicaid members with multiple chronic conditions. Provider patient management payments were tied to the number of chronic conditions of MHH members. To assess the effects of an Iowa MHH program on total spending, emergency department (ED) utilization, and ED spending. Claims data from January 2011 through December 2013; per member per month unit of analysis. We use a difference-in-difference regression design comparing pre/post outcomes for MHH members to pre/post outcomes for Medicaid members not participating in the MHH. We include individual fixed effects and matched controls to minimize the potential for confounding. In addition, we include a series of administrative covariates to control for individual demographic and geographic variation. Participation in the MHH program reduced spending by $132 per member per month. There is also evidence that the largest cost savings occur with a lag, as those in the program longer than a year showed the most savings. Members were less likely to visit the ED compared with traditional Medicaid recipients and ED spending was also lower for MHH members. Participation in a MHH program led to fewer ED visits and lower overall spending among Medicaid recipients in Iowa.

Implementation of Integrated Health Homes and Health Outcomes for Persons With Serious Mental Illness in Los Angeles County.

The Medicaid health home option of the Affordable Care Act provides a new opportunity to address the fragmented system of care for persons with serious mental illness. This study examined the implementation of integrated health homes in Los Angeles County. Longitudinal data on client-reported physical health status, clinician-reported mental health recovery, and screening for common chronic conditions among 1,941 persons enrolled in integrated care programs for serious mental illness and chronic general medical illness were combined with site visit data measuring the level of integration of general medical and mental health care among ten integrated care programs. Various analyses were used to compare outcomes by level of program integration (generalized estimating equations for physical health status and mental health recovery and logistic regression and chi-square tests for screening for common chronic conditions and clinical risk factors). Clients in more highly integrated programs had greater improvements in physical health status and mental health recovery and higher rates of screening for common chronic conditions compared with clients in less integrated programs. They also had greater reductions in hypertension but a worrisome increase in prediabetes and diabetes. Highly integrated mental health and general medical programs were associated with greater improvements in health outcomes compared with less integrated programs. Additional research is necessary to identify predictors of integration, to determine which aspects of integration drive improvements in health outcomes, and to identify strategies to increase integration within less integrated programs. Efforts are needed to coordinate pharmacotherapy, including increased consideration of the metabolic effects of antipsychotic medication.

Social Work Leadership as Ambassadors of Health Care Reform: Developing and Implementing a Health Home Program Within a Large Urban Health System

Beginning in 2011, The Mount Sinai Hospital participated in the New York State Department of Health Medicaid Health Home (HH) program, evolving into what is now the Mount Sinai Health Home (MSHH). The lead HH designation required social work leadership to develop and implement this initiative within a large health system, consisting of five New York City area hospitals. Additionally, strategic partnerships with sub-contracted, community based organizations and Medicaid Managed Care Organizations (MCOs) were essential to the HH’s success, and were facilitated by inter- and intra-organization collaboration. This article provides an overview of the HH model and discusses the process by which MSHH was formed, the integral role of social work in its development and success, challenges and lessons learned, and recommendations for the development of the profession’s future workforce. The authors intend to leave the reader with a model of social work leadership within the current environment of health care reform, and to exemplify social work care coordination and engagement of a hard to reach patient population.

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AbstractCalifornia Audit of Proposition 63 Calls for More Oversight of County ProgramsConnecticut School MH Report Reveals Need for Community CollaborationsReport Examines Overview of Medicaid Health Home CoverageSSA Changes ‘Mental Retardation’ to ‘Intellectual Disability’Enhancing School‐ and Community‐Based Mental Health Services for ChildrenLegislation Requires Key Stakeholders to Create Mental Health Plan for StudentsState NewsNames in the NewsComing up

Collaborative Care Well Suited to New Medicaid Health Home Option

Collaborative Care Well Suited to New Medicaid Health Home Option