Recovery NH takes statewide approach to drug addiction, mental health

PORTSMOUTH — In an interview, Deborah Fournier, New Hampshire Medicaid director, outlined what may be the most comprehensive approach to the opioid crisis yet seen in the state.

On Jan. 5, 2016, the Centers for Medicare and Medicaid Services approved New Hampshire’s Section 1115 Research and Demonstration Transformation Waiver, #11-W-00301/ 1 to access new federal funding to help transform its behavioral health delivery system. The waiver has four main targets:

n Deliver integrated physical and behavioral health care that better addresses the full range of individuals’ needs.

n Expand capacity to address emerging and ongoing behavioral health needs in an appropriate setting.

n Reduce gaps in care during transitions across care settings by improving coordination across providers and linking patients with community supports.

n Move 50 percent of Medicaid reimbursement to alternative payment models by the end of the demonstration period.

The program that evolved is called DSRIP, the delivery system reform incentive program. It has allowed integrated delivery networks to be created in seven regions, effectively covering the entire state. Locally, we are part of the Seacoast and Strafford region, which has 25,440 Medicaid members.

Fournier said DSRIP is designed to take a comprehensive look at how New Hampshire delivers behavioral health care, which includes both substance abuse and mental health issues. Here’s how the program is envisioned to work:

“Medicaid is a publicly funded medical health program,” Fournier said. “It is designed for a certain population, including children, pregnant women, seniors, people with disabilities, low-income parents and low-income adults. It pays insurance costs for about 187,000 people, or about 10 percent of our population.”

All states are eligible for Medicaid programs, which has the federal government paying a matching percent of the cost (50 percent in New Hampshire), the rest funded through the state. Fournier said that if the state chooses to participate, there are federal parameters that must be met to get federal funding.

DSRIP will bring in $150 million to the state, for a five-year program.

“We entered into negotiations with CMS (Centers for Medicare and Medicaid Services) to talk about programs we need that do not necessarily match the program criteria,” Fournier said. “It was a long, hard negotiation, lasting over one year. We did this because we know we have a crisis of addiction and mental services.”

Receiving approval, the program will allocate $30 million for 2016. It is the first year of efforts to improve the way behavioral health delivers services to Medicaid users, in both key areas. Integration of services is to be done, intending to make services more available, and more efficient in how they are offered.

“One thing we know is we have a need to build capacity, the people who will offer services in communities,” Fournier said. “Each region may have different needs and the personnel needs will be different, including both medical and non-medical partners.”

For example, Fournier said, statistics show that 50 percent of people who die from suicide had been seen by a provider within 30 days of their death.

“One problem is that people seen for medical reasons have their vital signs checked, but are not asked about their mental health,” Fournier said. “And people seen by mental health services are not asked about their physical health. That needs to change. We need to do a better job of applying services for a person’s total needs.”

Transitioning for people in trouble is another area of need. Fournier said correctional personnel are aware that people are being released who have substance abuse issues.

“Those people wind up back in the system because there is no ongoing support available to them,” Fournier said. “We need support services, or a constellation of services to meet the needs. The same thing applies to a person coming out of a 28-day rehab program. We need more boots on the ground to identify people who need help and to support transitional phases.”

Fournier explained the very complex processes being put in place that will potentially address the disassociation that currently exists.

“We have the seven IDNs now and each had to apply for funding,” Fournier said. “The application process ended in June and we did the approval process. Now, the IDNs are eligible this year for a share of capacity building funds. These can be used for project planning, retention and recruitment.”

Project plans will be submitted with very specific criteria of what they must accomplish and how they’ll do it. That includes assessing their region and determining the needs, which Fournier said might be different from region to region.

“We lost 492 people to overdoses last year,” Fournier said. “We expect that number to be higher this year based on what we have already seen.”

Project plans were due Oct. 31. State officials will vet the plans and they will be publicly reviewed in December.

“At that time we will make recommendations on the plans,” Fournier said. “Then in years two through five, regions will be working on those project plans. There are metrics in place that each region must meet to get money in the future years. This is a deliberate attempt to remove the idea of reimbursement for services and making it outcome based.”

The region plans must include aspects of mental health and substance abuse programs, as well as hospitals or clinics, and medical and public personnel. Every IDN must have an administrative lead, who is responsible for implementing the project plans. The IDN must include a correctional facility and a county nursing home.

“This has to be community based and we are excited about it,” Fournier said. “Because of this, we can look at things not traditionally included in Medicaid, like housing and food.”

“We are coming to the end of the first year of DSRIP,” said Fournier. “We will review where we are before beginning with next year’s implementation. Beginning next year, regions will report in July and in February.”

Fournier said one of their biggest hopes for the plan is that some providers will land on a new or better approach to the integration.

“Then we can look at that to see if/how it can be implemented in another region,” Fournier said. ‘We know there is no panacea for this crisis. This is a science experiment, one we all hope is successful.”