Missouri currently operates two Section 2703 Health Home programs with a focus on primary care and behavioral health integration that work in tandem to deliver improved care for qualifying children and adult Medicaid beneficiaries.

In October 2011, Missouri became the first state in the nation to receive approval of a Medicaid Health Home State Plan Amendment (SPA) to implement its Community Mental Health Center (CMHC) Healthcare Home program. This program is designed to improve the quality of care delivered to individuals with qualifying physical and mental health conditions. Through the program, participating CMHCs co-locate physical and behavioral health care services in the mental health setting in an effort to increase access to integrated and comprehensive care.

In December 2011, Missouri received approval for a second SPA to implement Primary Care Health Homes (PCHH) specifically targeting individuals with multiple, qualifying chronic physical conditions. Primary Care Health Homes share many of the same core elements as CMHC Healthcare Homes and include behavioral health staff in primary care settings to ensure access to integrated care.

Though the two programs are administered via separate state agencies—the Missouri Department of Mental Health and the Missouri Department of Social Services—the state has made a conscious effort to coordinate between the two programs to ensure effective and efficient implementation.

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Published: July 2015

 Program Components

Community Mental Health Center (CMHC) Healthcare Home
Missouri launched the first CMHC Healthcare Home program on January 1, 2012 to provide improved care to Medicaid beneficiaries with behavioral health conditions. The CMHC Healthcare Homes leverage the core Section 2703 Health Home elements such as comprehensive care management, care coordination, health promotion, and community referral services with a focus on delivering integrated physical and mental health.

To be eligible to participate, Medicaid beneficiaries must meet one of three qualifying criteria:

  • be an adult with a serious and persistent mental illness (SPMI) or a child with serious emotional disturbance (SED)
  • have a mental health condition and a substance use disorder (SUD)
  • have a mental health condition or SUD and one other chronic condition or chronic disease risk factor

Qualifying chronic conditions in the CMHC Healthcare Home program include diabetes, asthma/COPD, cardiovascular disease, developmental disabilities, being overweight, or using tobacco.

To serve as a Healthcare Home, CMHCs must effectively co-locate primary care and behavioral health services. This requires CMHCs to embed Primary Care Physician Consultants in their practices that are responsible for establishing disease management priorities and providing chronic disease education and consultation to other CMHC staff such as psychiatrists and care managers. Additional required CMHC Healthcare Home staff include:

  • Healthcare Home Director to oversee practice transformation and daily operation
  • Nurse Care Manager(s) to provide wellness education and assist with managing patient care
  • Administrative support staff

Beyond staffing, CMHC Healthcare Homes are expected to leverage health information technology to deliver comprehensive care management services. CMHCs use specific data analytic tools including CyberAccess, a web-based Medicaid data system that allows providers to view patient histories, and disease management and medication adherence reports.

As of October 2014, 11% of enrollees are children and youth. All enrolled children have a serious emotional disturbance diagnosis and the most common physical conditions for children include asthma, obesity, and developmental disabilities.

Primary Care Health Homes (PCHH)
Missouri’s Primary Care Health Homes (PCHH) also went into effect on January 1, 2012. The targeted Medicaid population for PCHHs are individuals with multiple, chronic physical conditions. Enrollees must have at least two qualifying chronic conditions for the PCHH. Examples of qualifying chronic conditions for the PCHH program are the same as for the CMHC Healthcare Home program.

Currently, children only account for approximately 3% of PCHH enrollees due to the eligibility requirement of having at least two chronic physical conditions and the nature of qualifying conditions. Missouri is considering amending its SPA to enable children with only asthma or obesity to participate in the program.

The core PCHH services are similar to those of the CMHC Healthcare Home and include comprehensive care management, care coordination, health promotion, and referral to community-based services. The PCHH also includes an emphasis on comprehensive transitional care services to ensure smooth patient transitions out of inpatient settings.

PCHH team members are comprised of many of the same staff as CMHC Healthcare Homes including a Health Home Director and Nurse Care Manager. However, instead of a Primary Care Physician Consultant, PCHHs include a Behavioral Health Consultant to assist primary care teams in managing patients with mental health and substance use disorders and a designated care coordinator responsible for tracking referrals, managing data, and assisting patients with appointment and prescription reminders.

PCHH providers must meet additional criteria including:

  • serving a minimum percentage of Medicaid/uninsured patients (adults and children)
  • using electronic medical records (EMR) for 6 months
  • applying for patient-centered medial home recognition through the National Committee for Quality Assurance (NCQA) within 18 months

Current PCHH sites include 18 federally qualified health centers (FQHCs) and 6 hospitals.

 Payment Model

In addition to fee-for-service (FFS) reimbursement, participating providers receive Per Member Per Month (PMPM) payments to cover the costs of required Health Home staff, data monitoring and reporting, and training. The current PMPM rate is $81.92 for Community Mental Health Center Healthcare Homes and $62.47 for Primary Care Health Homes. Providing care management monitoring or other documented Health Homes services to an individual triggers the PMPM payments. Going forward, Missouri is exploring adding shared savings and incentive payment components to its payment model.

 Outcomes

Despite the challenges in putting in place the nation’s first approved Health Home initiative, Community Mental Health Center Healthcare Homes have shown great progress in improving clinical outcomes and impacting the service delivery system. Much of the data has been collected on the adult population and shows positive impacts on multiple adult measures.

Due to the fact that children and youth make up a small percentage of total enrollees, the state has limited findings for children. Missouri is trying to tailor the program to better meet the unique needs of children going forward. For example, since serving a child entails working with a family and not just one individual, the state is considering significant changes to increase the capacity of staff that serve children.

 Fast Facts

  • 652,138: The number of children ever enrolled in Medicaid and CHIP in Missouri in FY 2013 (559,265 Medicaid; 92,918 CHIP)
  • 85.5%: The participation rate for children eligible for the Missouri Medicaid/CHIP program
  • 88.3%: The national participation rate for those eligible for the Medicaid/CHIP program