By Grace Anglin, Adam Swinburn, Leslie Foster, Cindy Brach, and Linda Bergofsky
About This Guide
Part 1: An Introduction to Care Management Entities (CMEs)
A Potential Solution: CMEs
CMEs Impact Youth Outcomes and Costs
Part 2: Assessing State Readiness to Design and Implement CMEs
Part 3: Strategies for Designing a CME
Strategy 1: Work with Stakeholders
Strategy 2: Consult CME Experts
Strategy 3: Use Data to Drive Decisions
Part 4: CME Design Features
Design Feature 1: Funding Mechanisms
Design Feature 2: Management Structure
Design Feature 3: Eligibility Criteria
Design Feature 4: Services
Design Feature 5: Eligibility and Training to be a CME
Design Feature 6: Payment Model and Rate
Design Feature 7: Quality Monitoring and Evaluation
Appendix A: Brief History of CMEs
Appendix B: Key CME Design Features in CHIPRA Quality Demonstration States, as of June 2014
The CHIPRA Quality Demonstration Grant Program
In February 2010, the Centers for Medicare & Medicaid Services (CMS) awarded 10 grants, funding 18 States, to improve the quality of health care for children enrolled in Medicaid and the Children's Health Insurance Program (CHIP). Funded by the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), the CHIPRA Quality Demonstration Grant Program aims to identify effective, replicable strategies for enhancing quality of health care for children. With funding from CMS, the Agency for Healthcare Research and Quality (AHRQ) is leading the national evaluation of these demonstrations.
The 18 demonstration States are implementing 52 projects in five general categories:
The demonstration began on February 22, 2010 and will conclude on February 21, 2015. The national evaluation of the grant program started on August 8, 2010 and will be completed by September 8, 2015.
Additional information about the national evaluation and the CHIPRA quality demonstration is available at http://www.ahrq.gov/policymakers/chipra/demoeval/.
The development of this Implementation Guide, and the overall national evaluation of the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Quality Demonstration Grant Program, is supported by a contract (HHSA29020090002191) from the Agency for Healthcare Research and Quality (AHRQ) to Mathematica Policy Research and its partners, the Urban Institute and AcademyHealth. Special thanks are due to Karen LLanos and Elizabeth Hill at the Centers for Medicare & Medicaid Services (CMS) and our colleagues for their careful review and many helpful comments. We particularly appreciate the help received from CHIPRA quality demonstration staff, Care Management Entity (CME) staff, and other stakeholders in Maryland, Georgia, and Wyoming, as well as the input we received from staff at the Center for Health Care Strategies and the Human Service Collaborative. We are grateful for the time they spent answering many questions during our site visits and commenting on an early draft of this Guide. The observations in this document represent the views of the authors and do not necessarily reflect the opinions or perspectives of any State or Federal agency. This document is in the public domain and may be used and reprinted without permission.
Youth with complex behavioral health needs face a range of challenges and are at risk for poor healthand education outcomes. They often receive services from multiple agencies, and these agencies may not always coordinate services and care plans for these youth.
When a youth's behavioral health and psychosocial needs are not addressed in a holistic manner, families may find themselves cycling in and out of crises. Moreover, the youth themselves may end up in restrictive placements that separate them from their families and communities and increase costs for the State.
Care Management Entities (CMEs) are designed to coordinate services provided by the many State agencies that serve youth with complex behavioral health needs. By ensuring services are comprehensive but not duplicative, CMEs can improve outcomes for these youth and their families and lower costs to States.
This Implementation Guide provides information about the CME design process. We hope it will be helpful to States interested in implementing or improving CMEs for youth with complex behavioral health needs and their families. The guide may also be useful for county agencies if they are responsible for financing behavioral health or social services in the State.
To develop this Guide, we drew from the experiences of the three CHIPRA quality demonstration States that are using funds to implement or expand CMEs. Maryland and Georgia are using their CHIPRA quality demonstration funds to refine and expand their existing CMEs, which they initially developed through Substance Abuse and Mental Health Services Administration (SAMHSA) Systems of Care grants and the Medicaid Psychiatric Residential Treatment Facilities 1915(c) waiver demonstration. Wyoming is using CHIPRA quality demonstration funds to design and implement a CME for the State.
To gather information about these efforts, we conducted semi-structured interviews in the summer of 2012 and again in the spring of 2014 with State CHIPRA quality demonstration staff, CME staff, and representatives from various child-serving agencies and family advocacy organizations. We also used information from semiannual progress reports that CHIPRA quality demonstration States submitted to the Centers for Medicaid & Medicare Services (CMS). We augmented this information with a focused review of the literature on CMEs and by asking CME experts to comment on an early draft of the Guide.
This Guide consists of four parts:
- Part 1: An Introduction to CMEs. Read this section to learn more about CMEs and their potential for enhancing services for youth with complex behavioral health needs.
- Part 2: Assessing State Readiness to Design and Implement CMEs. Read this section to learn about factors that may facilitate CME implementation and to help assess State readiness to move forward with CME design.
- Part 3: Strategies for Designing a CME. Use the strategies in this section to help design a CME.
- Part 4: CME Design Features. Use this section to learn about different CME design features and the tradeoffs associated with them.
Each section draws on the experiences of the CHIPRA quality demonstration States and references additional resources.