Behavioral Health and Developmental Disabilities Administration MACMHB Fall Conference 10/27/14 1
Introductions Lisa Grost, Autism Section Manager, MDCH Nicole Dwyer, ASD Program Specialist, Detroit Wayne Mental Health Authority Christine Lennon, Children and Family Services Supervisor, North Country Community Mental Health Morgan VanDenBerg, Autism Behavioral Specialist, MDCH 2
Overview Updates on Autism and ABA in Michigan Autism Coordination from the PIHP perspective Regional success and challenges from the CMH perspective 3
Medicaid/MIChild Autism Benefit The Michigan Medicaid and MIChild Autism Benefit went into effect on April 1, 2013. Applied Behavior Analysis(ABA) is the approved Autism Benefit service. Children enrolled in the Autism Benefit are also eligible for any medically necessary services provide by the Managed Specialty Supports & Services Plan under the authority of Section 1915(b) of the Social Security Act (the b-waiver b-3s or b-3 services ) 4
Autism Program Updates Children 18 months to 6 years old 1,493 children covered by Medicaid/MIChild received diagnostic services 950+ children are enrolled in the Autism ABA Benefit 5,898 children received other medically necessary Medicaid services Monthly Autism Webinars the 3rd Wednesday of every month at 2 PM 5
2014 Autism ABA Benefit Beneficiaries 1000 900 800 700 600 500 504 563 612 643 700 755 832 903 936 400 300 200 100 0 6
Autism Site Reviews Submitted year one report April 1, 2013 July 31, 2014 to CMS Completed all 10 PIHP Autism Site Reviews as of September 30, 2014 Have not finished the analysis of all the data from each Region for year 2 s CMS report Encourage you all to join our monthly webinars if you can and review your site review reports for specifics and recommendations for your region 7
Michigan Year One CMS Report PIHP system changed dramatically from 18 to 10 entities during this first year of services. State appropriation of $2.6M in contracts to improve the autism services in 2014 100% compliance with the providers possessing professional credentialing of LLP, LP, BCBA, and CMHP Children not getting the amount, scope, duration, and frequency of ABA as identified in the plan of service Winter weather conditions, family attendance, and lack of providers identified as the contributing factors to this performance measure not being met 8
ABA Service Capacity Initial 2013 November 2013 February 2014 May 2014 Has capacity to provide ABA to additional children Does not have capacity to provide ABA to additional children 9
Michigan ABA Successes Families are reporting amazing improvements and the outcomes are changing their daily life 168% increase in BCBAs working in public and private sector with children with ASD from April 2012 (38) to March 2014 (102) 67 BCBAs and 56 other qualified professionals working with Medicaid/MIChild children with ASD in Michigan (May 2014) Behavior Analyst Certification Board reports 248 BCBA s in Michigan 10
Michigan ABA Successes $2.6M in autism contracts in 2014 $9M in autism contracts in 2015 Michigan now has 7 universities offering ABA degree programs up from 2 in 2012 (8 th in the works) 11
Michigan ABA Challenges ABA Providers ABA providers are indicating they have room for more children; MDCH staff have provided leads and we are learning regions are not following up on increasing capacity. This elevates our non-compliance with ABA. Meeting level of ABA service recommended and authorized as medically necessary PIHP Restructure (from 18 to 10) PIHP/CMH autism coordinators Training of behavioral support staff 12
PIHP Autism Benefit Children Enrolled 56 13 63 Region 1 Region 2 90 112 Region 3 Region4 75 Region 5 62 Region 6 Region 7 198 130 Region 8 Region 9 39 Region 10 13
Percent of children enrolled in the Autism Benefit 100 Michigan PIHP ABA Services % Received ABA 80 60 40 50 40 61 55 38 73 60 38 47 % Received ABA as outlined in IPOS 51 52 42 20 0 6 24 7 28 15 20 6 17 14
Autism Training Survey Top training needs identified include: Parent and Family Training Parent and Family Engagement Autism safety training for staff Family and peer mediated interventions Reimbursement: payments, cost settlement, etc. Annual Waiver Conference, 11/18-19, East Lansing https://www.macmhb.org/ 8 Sessions for Autism and ABA Anthony Ianni, Autism Alliance of Michigan, 11/18/14 15
Centers for Medicare and Medicaid Services (CMS) Bulletin July 7, 2014 CMS Bulletin Bulletin reviewed approaches available under Medicaid for providing services to individuals with Autism Spectrum Disorder (ASD) It also reviewed state obligations under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit, where states must cover all medically necessary services for children, including services to address ASD. MDCH is pursuing an expansion of behavioral intervention services for children with ASD beyond age 6 and we will update stakeholders about the policy and effective dates when they become more apparent 16
Resources Website www.michigan.gov/autism Created the Autism Benefit Map is an interactive map that can be used to get information about the Medicaid and MIChild Autism Benefit Coordinator in a specific region. Provider FAQ ispa Policy Links to codes and encounter reporting Other resource documents for Autism ABA Benefit 17
Community Mental Health: Autism Services Nicole Dwyer, Autism Benefit Specialist, Detroit Wayne Mental Health Authority 18
Medicaid/MIChild Autism Benefit Objectives Implementation Discussion: Learn the Detroit-Wayne County service delivery structure Strengths & challenges of a large system of care Understand where we are and where we move forward The PIHP Autism Coordinator s Role 19
Implementation Discussion DWMHA Wayne County Overview: Largest County in Michigan 1,775,273 residents 115,000 under the age of 5 1,400 under the age of 5 with potential ASD diagnosis 24% of residents live below poverty level 12% of households do not speak English as primary language 13% of people have an identified disability *U.S. Census Bureau 20
Implementation Discussion DWMHA Autism Benefit Overview: 435 Positive M-CHAT/SCQs have been identified 324 children have been found eligible for the benefit Service Structure: DWMHA contracts with 7 ABA Provider Agencies to provide allinclusive ABA Benefit Services 21
Implementation Discussion DWMHA Strengths: Motivated workforce Robust provider network Vision for future growth and improvement Universities, large hospital systems, and subject matter experts Challenges: Growing Pains Staff Retention Service Coordination Socially Significant Concerns for Population Served 22
Implementation Discussion Socially Significant Concerns for Medicaid Population Inappropriate behaviors (tantrums, SIB, meltdowns, physical aggression, elopement) Lack of independence in ADLS Sleeping and feeding issues Lack of or poor communication Lack of natural supports Lack of or limited transportation Generations of mental illness, trauma and/or poor coping skills CPS involvement Lack of stable housing, finances, family structure Distrust in the systems they are involved in Lack of education and knowledge of services
The Role of a PIHP Autism Waiver Coordinator Provide Administrative Oversight of the Benefit: Ensure that standards and policies are developed and implemented that are consistent with Federal and State guidelines Develop and provide oversight to service infrastructure Monitor performance indicators & utilization management Provide technical assistance to provider network Monitor the WSA and internal electronic record management Collaborate with PIHP departments on the needs of the program Identify processes and tools for efficiency Provide status updates to administration 24
The Role of a PIHP Autism Waiver Coordinator Provide Community Awareness: Develop and maintain external relationships with stakeholders, including schools, health plans, parent groups, public health, DHS, etc. Provide presentations to the system and community on the ASD Waiver Benefit and educate system on accessing care Train the system on Autism Spectrum Disorder, screening tools, and processes Conduct stakeholder workgroups & meetings Identify training needs for the system and community 25
The Role of a PIHP Autism Waiver Coordinator Clinical and Utilization Management Operations Ensure that services provided and documentation comply with ASD State Plan standards and quality Develop protocols for an monitor Utilization Management Monitor overall clinical care and quality with the ABA Service providers to assure that all systems are meeting individual and clinic performance goals Act as the PIHP point-person for the ASD Benefit Work with the MDCH Autism Team to provide clarification and address any questions related to the ASD Benefit 26
Autism Spectrum Services North Country Community Mental Health Christine Lennon MA, LLPC, CMHP
North Country Community Mental Health O Serving 6 counties in Northern Michigan: O Cheboygan O Emmet O Charlevoix O Gaylord O Antrim O Kalkaska
Current Numbers for the Autism Benefit O AS of 10/23/14: O 41 Referrals since April 1, 2013 O 12 children receiving direct ABA services. O 2 children currently ready for BCBA services. O 9 children waiting for parents to schedule testing. O 5 children aged out of the program. O 8 children did not meet criteria for ASD. O 2 children switched from Medicaid to private insurance. O 3 children s families did not return calls to pursue services.
Translation Each child for the ABA/Autism Benefit receives: O Intake assessment O Pre-plan O Plan of Service O Testing for the Autism Benefit: O Autism Diagnostic Observation Scale 2 O Autism Diagnostic Interview-Revised O Vineland Adaptive Daily Living Scales O O O Mullen Scales of Early Learning Wechsler Preschool and Primary Scale of Intelligence-III (WPPSI-III) or Wechsler Preschool and Primary Scale of Intelligence-IV (WPPSI- IV) Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP) O 5-20 hours of intensive, one-to-one ABA therapy per week at their home or in an office setting, 2-5 hours per day, 5 days per week
Challenges 1. Developing a process and plan for roll out O Forecasting: costs for programming O Forecasting: numbers of children to receive services O Forecasting: numbers of clinical service providers needed 2. Creating an infrastructure O Developing new documents, new processes, new pathways for services O Meetings/Presentations/Proposals: MDCH/finance/contracts/testing/supervision/PIHP/billing/contracted BCBA s and tutors/case managers/it/directors/board O Translating the ISPA into NCCMH language 3. Work Force Development O Limited number of staff dedicated to autism benefit services O Hiring Freeze O Limited number of BCBA providers O Limited number of ABA tutors O Beginning BCBA course sequence was like learning a NEW LANGUAGE
Challenges 1. Code issues: O Lack of codes, 2 direct services at once O Changing codes 2. How many hats can you wear at once? O Serving as clinician, administrator, supervisor, student, tester O Reading 4 million progress notes and HICF 3. Serving rural areas = TIME O Limited workforce O Getting to homes that are far apart O Travel costs for families O Winter: Closed schools/roads/weather advisories
NORTH COUNTRY COMMUNITY MENTAL HEALTH PCP MCHAT Positive ACCESS CENTER Self Referral, Early On,ISD Intake Assessment/Pre-Plan with Family TESTING ADIR/ADOS (cognitive/adaptive) POS with Support s Coordinator Denial (Offer other services as appropriate ) Negative Positive Submit to MDCH for approval Denial (Offer other services as appropriate ) Submit to UM Committee for approval Approved Denied Denial (Offer other services as appropriate ) Approved Support s Coordinator Updates POS for ABA Refer for VB- MAPP Evaluation Service Provided 3, 6 and 12 month POSR
Strengths O Resiliency O Passion for working with children O Tenacity
What I Have Learned O To create a common language for all of the many people involved O People in finance don t care what a motivating operation is O Just because I have read through the process 4000 times, doesn t mean other people have O I have a lot more to learn!
The Work
Owen
Owen July 2014 October 2014
Hope O I spent yesterday with my daughter and my grandson Owen. Owen is Autistic. In May Owen had limited space in the house, as most of it was gaited for his safety. He was non verbal, limited eye contact, and we were at a loss on how to help him acquire these safety skills. He was not allowed outside as he would run without direction or purpose. He is now able to play outside and will walk to the park holding fingers. He has never said Momma or Daddy or I love you but yesterday he said uhn and twa, for one and two and we celebrated. A glimmer of hope into a situation of this type is huge. Christine has been a full ray of sunshine for my daughter and grandson. I am beyond grateful for the Autism program at CMH and thought you should know.
Questions?
Thank You! Additional Information: www.michigan.gov/autism Nicole Dwyer, Detroit Wayne Mental Health Authority ndwyer@dwmha.com Lisa Grost, MDCH grostl@michigan.gov Christine Lennon, North Country CMH clennon@norcocmh.org Morgan VanDenBerg, MDCH vandenbergm@michigan.gov 41