Safety-net providers in states that have accepted the federal funding available for Medicaid expansion under the Affordable Care Act (ACA) are experiencing a positive ripple effect, where increased insurance coverage rates among patients and thus greater financial security for safety-net institutions are translating into better care. We found that safety-net providers in states that expand Medicaid are delivering more services and better-coordinated care than what is available in states rejecting the expansion.

Of particular interest is the effect of Medicaid expansion on attempts to integrate behavioral health services with primary health care — long a thorny issue for safety-net providers. Research has shown that the Affordable Care Act (ACA) has increased access to behavioral health services. We present case studies from two provider systems that illustrate some of the innovative approaches that are improving the quality of behavioral health care at safety-net institutions.

New Care Models In Kentucky And Nevada

Recently we spoke with executives at large Federally Qualified Health Centers (FQHCs) in Kentucky and Nevada — both states expanded Medicaid coverage to previously ineligible adults in 2014.

Family Health Centers (FHC), a seven-site system based in Louisville, Kentucky, has taken several steps to improve services for patients with behavioral health needs. FHC has hired new behavioral health staff and located them in all but the smallest, most rural center in the system. Clinical social workers and clinical psychologists are now part of the health care team in participating centers and are supported by other social workers and case managers.

The behavioral health providers are placed in the medical area of the centers, which allows them to conduct an immediate behavioral health consultation if the primary care provider requests one during a health visit. Known as a “warm handoff,” this integrated approach does not require the patient to make a second appointment and allows the team to develop a care plan on the spot. Patients who need more specialized mental health services can be referred to a psychiatric nurse practitioner on staff or to a community mental heath service center.

In addition, FHC has contracted with attorneys in a medical-legal partnership to address civil legal issues such as housing, family law, and special needs plans for children. Addressing these “outside the clinic” social factors can have a substantial benefit on a patient’s physical and mental health.

This innovative work is funded through the ACA in two ways. According to Bill Wagner, CEO of FHC:

Part of our expansion in behavioral health was made possible by new HRSA grants under the ACA, but [having more paying patients under] Medicaid expansion made it possible, too. It was a combination of these two factors here in Kentucky.

The Community Health Alliance (CHA) in Nevada is similarly using new approaches to behavioral health integration. With three sites in Reno, CHA has hired new clinical psychologists, clinical social workers, and psychiatric nurse practitioners to enable behavioral health services to be delivered on site. Like the Louisville centers, CHA uses the expanded staff to support warm handoffs.

In addition, CHA has gone beyond site-specific behavioral health integration to develop a new “Center for Complex Care,” based in part on a model from Cherry Street Health Services in Grand Rapids, Michigan. Qualifying patients at CHA have the option of receiving more personalized and team-based care at this new center, which has integrated teams consisting of a primary care provider, clinical social worker, care coordinator, and medical assistant. Psychiatric nurse practitioners and other clinical staff are available as needed. These providers have fewer patients to manage and are given time to work as a team to help the most complex patients with their needs.

Chuck Duarte, CEO of CHA, explains: “We would probably have not done the Center for Complex Care if we had not been in a state with expanded Medicaid. We would have had to be much more cautious with so many more uninsured patients.”

CHA now cares for newly Medicaid-eligible patients who had been served at state mental health facilities and those in the community who were not eligible for Medicaid before expansion.

Funding Innovative Approaches To Behavioral Health Services

These innovative approaches to behavioral health integration simply would not have taken place without the grant funds available to FQHCs under the Affordable Care Act, and the decisions by Kentucky and Nevada to accept federal funding to expand Medicaid coverage. These factors are offering providers the financial security and incentive not just to extend the health services they were already providing before the Medicaid expansion but also to jump in with both feet and try interesting approaches to the difficult problem of addressing their patients’ behavioral health needs while delivering primary care.

A key element in both systems is the use of an interdisciplinary team, which has been advocated as a key step toward building capacity to deliver behavioral health services. Both systems also noted the importance of asking primary care providers to screen patients for behavioral health needs, and also are seeking to expand their substance abuse services.

Hiring attorneys to address the social factors that affect patient health or creating an intensive team-based approach for the most complex patients also requires new funding and the knowledge that patients will have health coverage. While Medicaid dollars may not pay for such approaches directly, it is clear in these two health center experiences that Medicaid expansion is playing a critical role in driving integration and improvement in behavioral health care.

Medicaid Expansion: Driving Innovation In Behavioral Health Integration
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