Cost-effective care for high-risk youth in Medicaid

Editor's Note: This story is the first part of a two-part series on improving care of high-risk youth enrolled in Medicaid. This month, we cover the challenges of this population and new approaches being used. Next month, we examine the impact of improved quality on subsequent contacts with the juvenile justice system.

Children and youth enrolled in Medicaid are more likely to have mental health needs, including serious mental health needs, than children in the general population. Those with serious emotional and behavioral health challenges are a high-utilizing, high-cost child population.

"Certain Medicaid child populations, such as children in foster care, have particularly high behavioral health service use," says Kamala Allen, director of child health quality at the Center for Health Care Strategies (CHCS) in Hamilton, NJ.

Early detection and intervention is improved through effective implementation of early and periodic screening, diagnostics and treatment, and of Medicaid managed care organizations (MCOs) to organize and deliver care, according to Ms. Allen. "Early intervention and more coordinated care can ameliorate, and in some cases, avoid serious behavioral health needs among these children," she says.

Conversely, missed early opportunities for screening, diagnosis, and treatment have the opposite effect. Too often, this results in long-term reliance on high-cost services and poor health-related outcomes for these children and youth.

For children with serious behavioral health challenges, new care management and risk adjustment strategies, along with effective home- and community-based services, have emerged. "These can help to decrease overreliance on expensive hospital and residential care and address inappropriate poly-psychotropic medication use, which is another barrier to quality care for this population," says Ms. Allen.

Ms. Allen says that the increased focus on providing quality care under the Medicaid program is "a high-opportunity leverage point to provide evidence-informed services and customized care management approaches to these populations that take into account their unique needs."

Approaches are tested

CHCS worked with a multistate collaborative of MCOs to identify ways to deliver better, more cost-effective care to this group. The CHCS "Collaborative on Improving Managed Care Quality for Youth with Serious Behavioral Health Needs" tested some of these approaches.

Participating Medicaid MCOs implemented programs in these three areas, using a data-driven approach:

— developing care management programs targeted to children and youth who were likely, based on screening or prior utilization, to be high utilizers of intensive services;

— educating primary care physicians about the appropriate screening and treatment of children and youth for depression;

— avoiding or reducing the use of inpatient psychiatric hospitals and long-term, high-cost residential services among children for whom placements or continued stays were not clinically indicated.

Strategies involved the development and use of community-based mobile crisis and response systems, and education of providers and agencies responsible for the referral of children and youth into residential treatment settings. Provider "profiling" identified residential providers with large numbers of "discharge-ready" children.

As a result of implementing some of these approaches, ValueOptions–New Jersey, then the administrative services organization for New Jersey's children's behavioral health program, achieved a reduction in the census of children in out-of-home placement in the state. Length of stay was reduced for those children who remained in care.

After implementing a hospital diversion program to reduce the number of children and youth entering that level of treatment, King County Mental Health Plan in Washington State increased the number of children served in home- and community-based settings by 50%. In addition, the potential hospital admissions that went through the community-based alternative screening process increased from 7% to 22%.

Challenges are many

Even simply identifying the population is difficult. Youth with serious emotional disorders do not cluster into any one Medicaid eligibility category. They are in both the generally "healthy" Temporary Assistance for Needy Families population and the high-need foster care and Supplemental Security Income (SSI) eligibility groups.

"There is no Medicaid eligibility code for these children, as they are represented across eligibility categories," says Sheila A. Pires, senior consultant to the CHCS collaborative. "They often do not meet eligibility criteria for SSI and thus are only minimally captured in the SSI population."

There are often financing incentives that drive institutional rather than home and community-based treatment. Other challenges include changing provider practices, working with system partners, such as child welfare, in which these children also are involved, and "effectively engaging youth and families as full partners in care," says Ms. Allen.

Contact Ms. Allen at (609) 528-8400 or