Medical Homes and People with Mental Illness

A National Council Issue Brief

As states seek to reduce health care costs, many are looking toward the medical home concept as a structural way to provide improved primary care for adults. However the National Council for Community Behavioral Healthcare is concerned about how this will affect people with mental illness. Specifically, unless community mental health organizations are identified as fulfilling medical home requirements, we are concerned that people with mental illness will not have their mental health needs met by this new system. In addition, we are concerned that medical homes are being used to limit consumer choices, which is contrary to the original concept of improving care through coordination.

The concept of 'medical homes' was created in an attempt to provide more effective and cost-sensitive care to children with serious healthcare needs. However, there are a few states that have already implemented or are in the process of implementing this concept for adults as well, and several other states are soon to follow.¹  With the growing support from federal and state governments for medical homes, the National Council is worried about how this concept will shape the care people with mental illness receive. Conceptually, any effort to improve the quality and effectiveness of treatment should be commended; however, we are concerned that the needs of people with severe mental illness will not be met based on the available guidance for the establishment of medical homes. To ensure the proper care of people with mental illness, we believe that community mental health organizations must be clearly defined as allowable medical homes for children and adults with serious mental illness.

To date, only one state, Vermont, has completed a medical homes pilot in which community mental health organizations functioned as medical homes. Vermont used grant and state funds to house nurses at community mental health organizations to address diabetes care among people with serious mental illnesses. Vermont's experience is an example of how community mental health organizations might successfully operate as medical homes.

Medical Homes and Children
The medical home concept is already an established healthcare delivery model for children. In addition to its original meaning, as an integrated and coordinated service delivery model, "medical home" is also used to mean "a usual source of health care, such as a clinic, doctor's office or health maintenance organization."²  The implementation of the medical home model, using either definition, thus far raises concerns about the care of children and adults with serious mental health issues. Although the original concept explicitly contemplated serving children with serious mental health needs, subsequent initiatives have either failed to explicitly contemplate mental health organizations as medical homes or have relegated them to add-on service providers to be included on an "as needed" basis.

When developing the model home concept for children, the American Academy of Pediatrics (AAP) defined the target population as "children with special health care needs":
"Children...who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally."³ 

The medical home concept has not been defined as clearly as the target population vis-à-vis mental health care, but the definition is certainly broad enough to encompass mental health providers and, in certain situations, to encourage the designation of community mental health organizations as medical homes:

• The Health Resources and Services Administration (HRSA) highlights the following as key components to a medical home: geographical and financial accessibility, continuity of care, comprehensive care, and determination of needs and linkage to services.⁴  HRSA defines a medical home as "care that is accessible, family-centered, comprehensive, continuous, coordinated, comprehensive [sic], culturally competent, [and] compassionate."⁵ 
• The American Academy of Pediatrics (AAP) adds to other definitions by stating that the patient should know the physician and "be able to develop a partnership of mutual responsibility and trust."⁶ 
• In a meeting that included the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS), the value of medical homes was discussed as being a way to "rationalize care for the patient" and to allow consumers to have more choice.⁷ 
• The Early Childhood Initiative Foundation describes the core services provided in a medical home as "medical, dental, mental health, case management, nutrition, behavior management, [and] referrals to special services or resources."⁸ 

Although the underlying definition of the target population for medical homes clearly includes children with serious mental health needs, the planning and implementation of the model have focused on the pediatrician and not the mental health provider as the medical home, or the "leader" of the medical home service delivery team. When the AAP developed the National Medical Home Mentorship Program in 2001, the first twelve state teams included six people each, including a family physician and a family representative, but did not explicitly include a mental health provider, nor was one suggested as "integral to the implementation of a statewide strategic plan."⁹ 

State plans for creating medical homes for children reflect the AAP's approach. Utah, for example, rather than including mental health organizations in the planning process, lists as a "future goal" providing "education...to mental health providers."¹⁰  Hawaii's plan contemplates including mental health practitioners as providers of "related services," not as the medical home or part of the primary care team.¹¹  Texas' Medical Home Fact Sheet does not even list mental or behavioral health as an area of concern to be addressed.¹²  Slightly better is the Texas Parent to Parent Medical Home Toolkit, which mentions mental health just twice, both times as examples of referrals that can be made, but makes one mention of finding a pediatrician who specializes in behavioral issues to serve as the child's primary caregiver.¹³  Although none of the state plans specifically exclude community mental health organizations as medical homes, their planning framework and failure to explicitly address behavioral health as a primary issue for some children almost certainly precludes any consideration of community mental health organizations as medical homes or even as a primary partner in providing and coordinating care.

Medical Homes and Adults
Given that the role of community mental health organizations in children's medical homes is not clearly delineated, it is no surprise that when states have attempted to adopt this concept to adult service delivery, community mental health organizations have been similarly ignored or marginalized. Given the state Medicaid reform trend to impose "personal responsibility" requirements on recipients, the ability to designate a familiar and accessible community mental health provider as a medical home takes on additional significance.

In West Virginia's State Plan Amendment, medical homes are defined as "a team approach to providing health care and care management. Whether involving a primary care provider, specialist, or sub-specialist...the medical home maintains a centralized, comprehensive record of all health related services..."¹⁴  According to this definition, a medical home team could include a community mental health provider, and the provider's organization could be designated as a client's medical home if the organization is willing and able to maintain all of the client's health-related records. The danger, as with the implementation of children's medical homes, is that the West Virginia State Plan Amendment does not explicitly list community mental health organizations as eligible medical homes, which makes state officials less likely to conduct specific outreach to mental health providers, who may not realize they could be designated as medical homes.¹⁵  In the absence of explicit information, consumers are unlikely to know that they could designate their community mental health organization as a medical home.

The inability of consumers to designate community mental health centers as medical homes can have significant consequences. West Virginia's Medicaid State Plan Amendment also requires that beneficiaries must sign an agreement, stating among other things that they will seek out regular care at their assigned medical home.¹⁶  Once beneficiaries have signed this document, they will be placed on the Enhanced Plan (in which mental health services are available) as long as they abide by the agreement and only use emergency rooms for actual emergencies.¹⁷  For many adults with serious mental illness, the community mental health organization is their usual place to receive care, a place that is known to them and where they are known. If community mental health organizations are not identified as a medical home for these recipients, it seems unrealistic that a person with mental illness who has an established relationship with a mental health provider, will then go to and trust a different provider in a different setting, particularly if the assigned provider is not a mental health provider. The Enhanced Plan also requires individuals to be on time for pre-set appointments, take prescribed medications, and attend "health improvement programs,"¹⁸  all activities that can be especially challenging for persons with mental illnesses, especially if the medical home is a new place, with new people who do not know what accommodations may be necessary to enable the client to be successful in meeting the terms of the member agreement.

Under the West Virginia State Plan Amendment, if the person with mental illness does not follow the rules in the member agreement, they can be dropped from the Enhanced Plan to the Basic Plan, which does not provide necessary mental health services. Once a person is dropped from the Enhanced Plan, they cannot reapply for 12 months or until their Medicaid coverage is renewed. This scheme does not meet the needs of people with mental illness, and this is especially the case if community mental health organizations are not identified as allowable medical homes.

The Missouri Commission on Medicaid Reform has also recommended the use of medical homes for Medicaid recipients, citing the need for "better coordination and continuity of care."¹⁹  Like West Virginia, the recommendation is related to concerns about patient compliance and a desire to "lock" Medicaid recipients into medical homes.²⁰  Medicaid recipients, the report emphasizes, "are responsible for managing their own health status, including seeking healthcare at the right time, in the right place and with the right provider."²¹  The Commission report also recommends using medical homes as a way to hold providers accountable. Without medical homes and "with the ad hoc ability to jump from provider to provider, there is no incentive for either the provider or the participant to promote and follow best practices for healthcare."²² 

Unlike West Virginia's State Plan Amendment, however, the Missouri Medicaid Reform Commission Report explicitly cites the need for people with serious mental illness to have medical homes "through the [Department of Mental Health] Administrative Agents and Affiliates."²³  However, the report later recommends that the state assign Medicaid recipients to primary care physicians.²⁴ 

In Louisiana, the Health Care Redesign Collaborative specifically targets adults with serious mental illness and those with addictive disorders, among others, for medical homes.²⁵  The Collaborative lists behavioral health as a "key component" of a medical home.²⁶  Their proposal contemplates a "medical home extension" for people with "serious and complex behavioral healthcare issues," aimed at improving access to services.²⁷  However, the recommendations state that all medical home care will be coordinated through a primary care physician: "The decision to refer a person to an extension service system will be based on the clinical judgment of the primary care physician exercised in collaboration with the person and his or her family."²⁸ 

Similar ambiguities involving medical homes and community mental health organizations exist in other states that are adopting the model as part of Medicaid reform. Although no plan yet explicitly excludes community mental health organizations from being designated as medical homes, none expressly includes them. Some definitions are more problematic than others. Texas, for example, defines a medical home as "provid[ing] primary medical care and preventive health services and is the individual's and family's initial contact point when accessing health care."²⁹  Because mental health care is often not viewed as a vital component of health care, community mental health providers may have a difficult challenge convincing Texas state officials that they should be designated medical homes for people with mental illness whose primary health care relationship is with their community mental health providers.

As the medical homes concept is expanded to include adults, new opportunities are emerging. The Colorado Behavioral Healthcare Council recently succeeded in working with state officials to draft a more neutral definition of medical homes. (To read Colorado's new definition, visit www.nccbh.org/POLICY/ColoradoMedHomesDef.pdf) Their next challenge is convincing the primary care physicians who are developing a pilot medical homes project to use the new definition so that community mental health organizations can be so designated.

Recommendations
Because of the increased attention on medical homes, the National Council believes it is important to point out that medical homes, if implemented appropriately, could be of great benefit to people with mental illness. Several organizations, including the AAP, have cited the high costs associated with Emergency Department (ED) visits,29 bolstering the states' argument that people are using EDs for routine, non-emergent care and that efforts should be made to decrease this. In a recent national survey, 60% of the physicians surveyed said that the increase in psychiatric patients seeking care at emergency departments (ED) is negatively affecting access to emergency care for all patients by generating longer waiting times and limiting the availability of ED staff and ED beds for other patients.³⁰  Significantly, the Partnership for Medicaid has cited the decreased access to primary care as being closely linked to the increase in ED usage.³¹ 

Within this context, medical homes seem to be a viable solution to both reduce unnecessary ED usage and improve access to primary care. Vermont's pilot program has demonstrated that housing primary care personnel within community mental health organizations can reduce unnecessary hospitalizations for adults with mental illness who have diabetes and provide other health benefits. For people with mental illness, it is critical that community mental health organizations are clearly identified as eligible medical homes. Various locations are cited as being appropriate medical homes, such as outpatient clinics, community health centers, health departments, but community mental health organizations are rarely identified as an eligible or desirable medical home in any language on this subject. This lack of explicit language in state Medicaid plans and other materials on medical homes could be detrimental to people with mental illness, especially in states where failure to adhere to specific rules related to the medical home can result in decreased access to necessary mental health services.

In advocating for the inclusion of community mental health organizations as medical homes, the National Council cannot ignore the general medical needs of people with mental illness. A recent study highlighted the importance of providing physical health services to people with mental illness, concluding that people served by the public mental health system die 25 years younger than the general population—mainly due to chronic physical disabilities.³²  Many people with mental illness must rely on their community mental health providers to provide referrals for medical care and to serve as their advocates to ensure they receive needed services. Community mental health organizations should strive to create and sustain strong relationships with community health centers or other primary care providers, ideally by offering primary care on site within the community mental health organization or other collaborative care mechanisms. This type of relationship best achieves the ideal of what medical homes should be. As stated in Texas' plan, "[w]hen referring for...specialty/hospital services and health and health-related services, the medical home maintains the primary relationship with the individual and family, keeps abreast of the current status of the individual and family...and accepts them back into the medical home."³³  For people with mental illness, community mental health organizations would best serve their interests while acting as their medical home, addressing concerns over increased costs related to ED usage and coordinating other care, as needed.

As support continues to grow for the usage of medical homes to reduce costs elsewhere in the healthcare system, we must be mindful of the needs of people with mental illness. This is most readily achieved by identifying community mental health organizations as medical homes and working towards sustaining strong connections between community mental health organizations and community health centers.

Questions about this issue brief? Please contact Laura Galbreath at LauraG@thenationalcouncil.org.

¹ In Louisiana, for example, a recent report recommends redesigning the state's Medicaid system around the medical home concept. See Louisiana Health Care Redesign Collaborative Charter, Concept Paper for a Redesigned Health Care System for Region I, October 18, 2006, http://www.dhh.louisiana.gov/offices/publications/pubs-288/2896.pdf.
² Center on Budget and Policy Priorities, Improving Children's Health, http://www.cbpp.org/1-15-04health.htm.
³ American Academy of Pediatrics, The National Center of Medical Homes Initiatives, http://www.medicalhomeinfo.org/about/def_cshcn.html (emphasis added).
⁴ Sia, C., Partnership for Change: The Role of the Medical Home for CSHCN, Human Resources and Services Administration, http://www.hrsa.gov/reimbursement/disability/ppt6/default.htm.
⁵ Id.
⁶ American Academy of Pediatrics, The Medical Home, Pediatrics, 110:1, July 2002, pgs. 184-186, pg. 184.
⁷ Centers for Medicare and Medicaid Services, Invitational Meeting: Transforming Health Systems Through Leadership, Design, and Initiative, pg. 17, http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/
MMA646_Conference_Proceedings_p.pdf
⁸ The Early Childhood Initiative Foundation, Child Health and Well Being: The Medical Home Concept in Child Health care, http://www.teachmorelovemore.org/BestTrendsDetails.asp?faqid=219
⁹ American Academy of Pediatrics, The National Center of Medical Homes Initiatives, http://www.medicalhomeinfo.org/model/mission.html.
¹⁰ American Academy of Pediatrics, The National Center of Medical Homes Initiatives, National Medical Home Conference (January 2001), http://www.medicalhomeinfo.org/model/downloads/
NMHC%20proceedings%20with%20state%20plans.pdf.
¹¹ Id.
¹² Texas Department of State Health Services, Children with Special Health Care Needs Program, http://www.dshs.state.tx.us/cshcn/pdf/MedHome.pdf.
¹³ Texas Medical Home Toolkit, http://www.medicalhomeinfo.org/states/Downloads/
Texas%20Toolkit/Medical%20Home%20Toolkit_1.pdf.
¹⁴ West Virginia Department of Health and Human Services presentation, Slide 16, http://www.wvdhhr.org/bms/oAdministration/
bms_Redesign.ppt#303,1,Slide.
¹⁵ In response to the lack of clarity regarding medical homes and adults with serious mental health needs, one provider wrote to the West Virginia Medicaid Director requesting specific designation of community mental health organizations. (See Letter from Bob Hansen, Prestera Center for Mental Health Services, August 29, 2006, http://www.nccbh.org/POLICY/Letter%20to%20Atkins.pdf).
¹⁵ Centers for Medicare and Medicaid Services, West Virginia State Plan Amendment, Section 3.1, Attachment 3-pg. 1.
¹⁶ Gever, M., Medicaid Under the DRA: West Virginia Takes a Crack at Reform, National Conference of State Legislators, June 12, 2006, http://www.ncsl.org/programs/health/shn/2006/sn469/htm
¹⁷ Centers for Medicare and Medicaid Services, West Virginia State Plan Amendment, Section 3.1, Attachment 3-pg. 1.
¹⁸ Texas Department of State Health Services, THSteps Medical Home: The Medical Home Concept, http://www.dshs.state.tx.us/thsteps/medical_home.shtm.
¹⁹ Medicaid Reform Commission Report at 25, http://www.senate.mo.gov/medicaidreform/
MedicaidReformCommFinal-122205.pdf
²⁰ Id. at 25-26, 17.
²¹ Id. at 18 (emphasis added).
²² Id. at 50.
²³ Id. at 37.
²⁴ Id. at 50.
²⁵ Louisiana Health Care Redesign Collaborative Charter, Concept Paper for a Redesigned Health Care System for Region I at 5 (October 18, 2006) http://www.dhh.louisiana.gov/offices/publications/pubs-288/2896.pdf.
²⁶ Id. at 8.
²⁷ Id. at 10.
²⁸ Id. at 9.
²⁹ AAP, News Release: AAP Defines 'MedicalHome'—The Best Care for Children'
³⁰ Institute of Medicine Report, "Hospital-based Emergency Care: At the Breaking Point," pg. 48
³¹ Partnership for Medicaid, Reducing Inappropriate Emergency Room Use among Medicaid Recipients by Linking Them to a Regular Source of Care
³² Colton C., Manderscheid R., Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states, Preventing Chronic Disease, Vol. 3:2, April, 2006. Also available online: http://www.cdc.gov/pcd/issues/2006/apr/05_0180.htm.
³³ Texas Department of State Health Services, THSteps Medical Home: The Medical Home Concept