The Policy Ecology of Behavioral Health Homes: Case Study of Maryland’s Medicaid Health Home Program

Abstract

Behavioral health homes, shown to improve receipt of evidence-based medical services among people with serious mental illness in randomized clinical trials, have had limited results in real-world settings; nonetheless, these programs are spreading rapidly. To date, no studies have considered what set of policies is needed to support effective implementation of these programs. As a first step toward identifying an optimal set of policies to support behavioral health home implementation, we use the policy ecology framework to map the policies surrounding Maryland’s Medicaid behavioral health home program. Results suggest that existing policies fail to address important implementation barriers.

Introduction

Individuals with serious mental illnesses (SMIs) such as schizophrenia and bipolar disorder experience disproportionately high rates of comorbid medical conditions (De Hert et al. 2006; Janssen et al. 2015; Parks et al. 2006). Individuals with SMI are one and a half times more likely to have cardiovascular disease (Correll et al. 2017) and nearly two times more likely to have diabetes mellitus (Vancampfort et al. 2016) compared to those in the general population. The increased prevalence and mortality due to these conditions among individuals with SMI relative to those without contributes to a 10–20 year shortened life expectancy (Daumit et al. 2010; Olfson et al. 2015). Despite the high need for care for these individuals, fragmentation in the healthcare system reduces the accessibility of needed services (Horvitz-Lennon et al. 2006). This often results in sub-optimal quality of care for physical healthcare services among individuals with SMI (McGinty et al. 2015).

One model for addressing fragmentation and coordinating services for individuals with SMI is the “behavioral health home,” in which specialty mental health programs are responsible for coordinating and/or delivering physical healthcare services for people with SMI. A key rationale for this model, differentiating it from primary-care based health home efforts like the Primary Care Medical Home (PCMH), is that many individuals with SMI receive the majority of their healthcare services in the specialty mental health sector (Bao et al. 2013). Behavioral health homes have been shown in randomized clinical trials to improve outcomes related to utilization (e.g., increase primary care visits and increase emergency department visits), receipt of preventive care (e.g., vaccination and screening and monitoring for diabetes and blood pressure), and coordination and satisfaction with physical health care (Druss et al. 2001, 2017). The promising results of these RCTS helped lead to a proliferation of “real-world” behavioral health home models. In recent years, behavioral health homes have been created through two major U.S. initiatives: the Substance Abuse and Mental Health Services Administration’s Primary and Behavioral Health Care Integration (PBHCI) program, which supported the development of 213 behavioral health home programs at community mental health centers from 2009 to 2016 (SAMHSA 2016), and the Affordable Care Act’s Medicaid Health Home Waiver. The Medicaid health home waiver program, which creates a financing mechanism by which specialty mental health providers can be reimbursed for the provision or coordination of primary care services for a high-cost high-need population, has spurred widespread adoption of the behavioral health home model (CMS 2018a). As of September 2018, Seventeen states and Washington, D.C. have implemented behavioral health homes for individuals with SMI through the Medicaid waiver (CMS 2018c).

Evaluations of real-world behavioral health homes have shown limited and mixed effects on outcomes (Murphy et al. 2019). Studies have shown some beneficial effects on screening and monitoring for physical health conditions (e.g., diabetes and blood pressure) (Breslau et al. 2018b; Gilmer et al. 2016; Murphy et al. under review; Missouri Department of Health 2017; Tepper et al. 2017). However, studies of effects on utilization measures (e.g., inpatient stays, emergency department visits, outpatient primary care visits) have mixed results (Bandara et al. under review; Breslau et al. 2018a, b; Missouri Department of Health 2017; Krupski et al. 2016; Ohio Departmet of Medicaid 2015; Tepper et al. 2017). Evaluations of behavioral health home impact on health outcomes (e.g., cholesterol and diabetes control, weight management, smoking cessation) show small or no effects (Gilmer et al. 2016; Missouri Department of Health 2017; Scharf et al. 2016; Schuster et al. 2018; Tepper et al. 2017).

The limited impacts found in evaluations of these real-world behavioral health home programs are likely due, in part, to challenges related to implementation (Murphy et al. 2019). While behavioral health home implementation barriers are well documented—prominent barriers include lack of information sharing (Golembiewski et al. 2015; McGinty et al. 2018; Missouri Department of Health 2017; Ohio Departmet of Medicaid 2015; Scharf et al. 2014b), recruiting and retraining consumers (Annamalai et al. 2018; Golembiewski et al. 2015; Maragakis and RachBeisel 2015; Ohio Departmet of Medicaid 2015; Scharf et al. 2013, 2014a, b), and insufficient training for staff (Golembiewski et al. 2015; Missouri Department of Health 2017; Scharf et al. 2013; Scharf et al. 2014b)—the policy environment of behavioral health home implementation is not. A coordinated effort of policies is required for implementing complex programs such as behavioral health homes, however evidence on a model policy environment for these programs does not exist. As a first step toward defining a model, we use the Maryland behavioral health home model as a case study. We aim to delineate the existing policy environment supporting behavioral health home implementation in Maryland using the policy ecology framework (Raghavan et al. 2008), summarize prior literature surrounding the effectiveness of the policies within Maryland’s ecology, and consider additional and alternative policies that could better support behavioral health home implementation.

Maryland’s Medicaid Health Home Program

Since October 2013, 59 Medicaid behavioral health homes, created through the Affordable Care Act waiver program, have been implemented in psychiatric rehabilitation programs in Maryland (Maryland 2018). Psychiatric rehabilitation programs were chosen as the primary location of behavioral health home implementation in Maryland as a way to reach individuals with SMI where they already regularly receive care and because psychiatric rehabilitation programs had previous experience providing and coordinating mental health and social services for individuals with SMI (Maryland 2018). The behavioral health home adds the coordination of physical health care and delivery of other health home services, which include provision of basic preventive services and individual and family support services, to the psychiatric rehabilitation programs’ responsibilities. Full details of Maryland’s behavioral health home program have been described elsewhere (McGinty et al. 2018).

Similar to evaluations of behavioral health homes in other states, early evaluations in Maryland have found limited impacts of the model on outcomes related to utilization and quality of care. Maryland behavioral health homes were associated with reduced likelihood of all-cause emergency department visits, with the overall reduction driven by reduced emergency department visits for physical health conditions (Bandara et al. under review). They had no impact on measures of the quality of care for diabetes or cardiovascular disease, but did increase the likelihood of cancer screening for cervical and breast cancers (McGinty et al. under review; Murphy et al. under review).

Policy Ecology Framework

Developed by Raghavan et al. (2008), the policy ecology framework outlines four levels surrounding the service or program of interest that comprise the broader context of evidence-based practice implementation. The organizational level is the most proximal to the clinical encounter and consists of the organization in which the services are delivered. The regulatory and purchasing agency level is comprised of the regulatory and funding environment surrounding the organization. The political level refers to the legislative and advocacy efforts supporting the policy. The social level consists of the societal norms and subcultures that affect the policy and other levels of the framework. Policies at each of the four levels interact with and influence policies at the other levels. Raghavan et al. (2008) assert that successful implementation and long-term sustainment of evidence-based practices requires consideration and alignment of policies across the entire ecology. An adapted version of the framework, applied to behavioral health home implementation, is shown in Fig. 1. In this adaptation, policies are mapped onto the framework by level of enactment. The political level is renamed the legislative level to reflect the focus on policy enactment and the social level is represented by the social context, which both impacts and is impacted by policies at the other three levels but which is not a level of policy enactment in and of itself.

Fig. 1.

Behavioral health home policy ecology

Examples of key factors within the social context include societal and provider stigma and health system and community resources and relationships. Individuals with SMI are a highly stigmatized group (Pescosolido et al. 2013). Negative attitudes toward these individuals persist within the healthcare setting and, for behavioral health homes, this may impact clinical how people with SMI and mental health and primary care providers interact with each other and make decisions regarding treatment (Corrigan 2004; Stone et al. 2019; Thornicroft et al. 2007). Resources and relationships with health systems and other community organizations are especially important for behavioral health homes, as many of their primary goals are related to coordinating and making referrals for care. Additionally, these resources and relationships may impact the ability of behavioral health home participants to access care (Bao et al. 2013; McGinty et al. 2018; Scharf et al. 2013).

Case Study Methods

Policies (i.e., legislation, regulations, and rules) supporting implementation of Maryland behavioral health homes were identified using the Code of Maryland Regulations (COMAR 2018) and Maryland Department of Health’s Maryland Chronic Health Homes website (Maryland 2018). Policies related to behavioral health home implementation were identified and assigned to a level of the policy ecology using an iterative process with study team members.

Policy Ecology of Maryland’s Medicaid Health Home Program

Legislative Level

At the legislative level, the sole lever was the creation of an optional Medicaid State Plan waiver in the 2010 Affordable Care Act, Section 2703 (Table 1) (CMS 2018a). This waiver created a Medicaid reimbursement mechanism that allowed states to establish health homes to “integrate and coordinate all primary, acute, behavioral health, and long-term services and supports” for a defined population with chronic mental or physical health conditions (CMS 2018a). States receive an enhanced 90% Federal Medical Assistance Percentage reimbursement rate for the first 2 years of health home service provision and programs are required to report outcomes on core quality and utilization measures to the state (CMS 2018a). Other specifications of the health home target population, structure, and financing are left up to the states (CMS 2018a).

Table 1.

Policy strategies supporting implementation of Maryland behavioral health homes enacted at the legislative level

Policy strategy

Details

The Affordable Care Act (ACA) of 2010, Section 2703—Medicaid health home waiver

The ACA created an optional Medicaid State Plan benefit which allowed states to create health homes and bill Medicaid for services to coordinate care for Medicaid recipients with chronic conditions Eligible health home participants must have two or more chronic conditions (mental health, substance use, asthma, diabetes, heart disease, obesity), have one chronic condition and are at risk for a second, or have one serious and persistent mental health condition Eligible health home providers can be a designated provider (e.g., physician, community health center, behavioral health service agency) or a team of health professionals (e.g., physicians, behavioral health professionals, social workers) Health home services billable to Medicaid include comprehensive care management, care coordination, health promotion, comprehensive transitional care/follow-up, patient and family support, and referral to community and social support services States are required to report health home data to the Centers for Medicaid and Medicare Services (CMS). Each year, CMS creates a set of core quality and utilization measures (e.g., number of participants with hypertension whose blood pressure is adequately controlled, number of emergency department visits). In addition to these measures, states are expected to collect information on goals and measures specific to their programs In the first 2 years of a program, the state is eligible for an enhanced 90% Federal Medical Assistance Percentage for reimbursement of health home services. Development of payment methodologies (e.g., per-member per-month, fixed rates) for health home services were left to the states.

Regulatory and Purchasing Agency Level

In Maryland, the behavioral health home policies implemented at the regulatory and purchasing agency level are related to licensure, accreditation, evaluation, and program requirements (Table 2). To operate as a behavioral health home, organizations must be licensed by the state as a psychiatric rehabilitation program. The regulatory body for these programs, as well as behavioral health homes, is the Maryland Department of Health (COMAR 2018).

Table 2.

Policy strategies supporting implementation of Maryland behavioral health homes enacted at the regulatory and purchasing agency level

Policy strategies	Details
State licensure	Programs implementing behavioral health homes must be licensed by the state of Maryland as a psychiatric rehabilitation program (PRP)
Accreditation	PRPs in Maryland must be accredited as a behavioral health home by either the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF) The Joint Commission’s Behavioral Health Home Certification includes measures of the behavioral health home’s ability to: Assess and document data for at least the following chronic conditions: metabolic syndrome, diabetes, hypertension, heart disease, asthma, chronic obstructive pulmonary disease, Hepatitis C, HIV/AIDS, and obesity Identify and adapt to health literacy needs of participants Manage transition of care and access to integrated care Use health information technology (HIT) to: support continuity of care and provision of integrated care, document and track care, support disease management, support preventive care, create reports, facilitate information exchange, support performance measurement CARF’s Health Home Standards include measures of the behavioral health home’s: Program description (defining population served, how services will be provided/accessed/coordinated, referral procedures, and process for primary health care coordination and disease management) Provision of: health promotion/education, comprehensive care management, care coordination, comprehensive transitional care, individual and family support services, and referral to needed community/ social supports Use of flexible scheduling to enhances access Capacity for same day or next day visits, same-day staff response to phone calls, and after-hours access
Evaluation and reporting	The Centers for Medicaid and Medicare Services (CMS) and the Maryland Department of Health (MDH) require behavioral health homes to report on monthly enrollment, participant characteristics, health care utilization and access, and health care quality measures MDH requires monthly reports detailing behavioral health home service delivery and participant health and social outcomes as well as program assessments every six months demonstrating that all regulatory requirements are being met and that a quality improvement plan is being implemented The behavioral health homes must use eMedicaid, an online portal used by the state to document and bill for Medicaid services, to: Input information related to participants’ services and health at least monthly Generate monthly reports documenting service delivery and participants’ health and social outcomes Update participant diagnoses and outcomes every 6 months
Participant eligibility	Individuals are eligible to participate in behavioral health homes if they receive Maryland Medical Assistance and receive outpatient mental health rehabilitation or treatment services from a PRP
Program eligibility	To be eligible as a behavioral health home, programs must meet regulations laid out in the Code of Maryland Regulations
Staffing	Minimum behavioral health home staffing requirements include: Health home care manager (.5 FTE per 125 participants). A nurse practitioner, registered nurse, or physician’s assistant who leads the implementation and coordination of health home activities Health home director (0.5 FTE per 125 participants). An individual with a bachelor’s degree and 2 years’ experience in health administration, a master’s degree in a related field, or a registered nurse, physician, or nurse practitioner who leads the clinical aspects of the health home (e.g., facilitating health education groups, providing training on medical diseases, treatments, and medications). The health home director can also serve as the health home care manager provided that requirements for both positions are met Physician or nurse practitioner consultant (1.5 h per participant per year). The consultant reviews participant care documents and assists with treatment planning Administrative support staff as needed to meet the service provision and reporting requirements
Health information technology (HIT)	HIT requirements for behavioral health homes include: Registering with the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange, to receive alerts for hospital encounter Registering with CRISP or state Administrative Services Only (ASO) program to receive access to real-time pharmacy data Maintaining an electronic database with ability to maintain up-to-date contact information and record/ review clinical appointments Using eMedicaid, an online portal used by the state to document and bill for Medicaid services, or another HIT tool that feeds into eMedicaid to input information related to evaluation and reporting requirements
Internal protocols	Behavioral health homes must develop internal protocol for reviewing and responding to hospital encounter alerts and pharmacy use data
Communication	Behavioral health home regulations related to communication between providers (within and outside of the behavioral health home) and participants include: Convening health home staff meetings every 6 months at minimum Collaborating with Managed Care Organizations and the ASO Providing on-call and crisis intervention services by telephone 24 h a day, 7 days a week Using HIT to facilitate communication between health home staff, participants, caregivers, and other providers
Participant documentation	Behavioral health homes are required to maintain a file for each participant that includes a signed consent form, an initial assessment of the participant’s health and social service needs and a care plan, updated every 6 months. Care plans may be combined with existing PRP care plans and must include participant goals (and time frames and proposed interventions for meeting goals), relevant community networks and supports, optimal clinical outcomes, and participant and nurse care manager signatures
Payment mechanism	Behavioral health homes are reimbursed at a monthly rate of $102.86 per participant. Reimbursement is contingent upon meeting behavioral health home requirements (e.g., two services per-member per-month)
Service delivery	Reimbursable behavioral health home services include comprehensive care management, care coordination and health promotion, comprehensive transitional care/follow-up, individual and family support, and referral to community and social support services. HIT should be used to link services, as appropriate, and service delivery must be documented in eMedicaid. Behavioral health home participants must receive at least two services per month. Components of each service are described below Comprehensive care management: Conduct initial assessment of patient physical, mental, substance use, and social service needs Develop care plan (described above) Delineate staff roles and providers involved in participant care Monitor and reassess participant health status and progress toward goals through monitoring of population health status and evaluation of outcomes Care coordination and health promotion: Coordinate and provide health care services, preventive and health promotion services, mental health and substance use services, chronic disease management services, and long-term care and support services Coordinate services and support including appointment scheduling, referrals and follow-up monitoring, hospital discharge processes, and communication with other providers Assign a health home care manager to each participant Develop policies and procedures to facilitate coordination between primary care, specialists, and behavioral health providers and community-based organizations Develop security protocols to protect confidential health information Assist participants with the implementation of their care plan (e.g. health education) Coordinate with parents and families of participants who are minors Use eMedicaid to document, review, and report health home service delivery Comprehensive transitional care/follow-up: Provide services to streamline plans of care, reduce avoidable hospital admissions and emergency department use, ease transition to long-term services, and ensure appropriate follow-up across settings Increase participants’ ability to manage care and live safely in community Utilize CRISP alerts and follow up with participants within 2 business days of hospital discharge Individual and family support services: Advocate for and assist participants in accessing needed resources and medications Utilize peer supports, support groups, and self-care programs Ensure that communication is language, literacy, and culturally appropriate Referral to community and social support services: Assist in accessing and coordinating medical assistance, disability benefits, subsidized or supported housing, personal needs support, peers support, or legal services
Provider trainings	Provider trainings/webinars are offered on the Department of Health website. Details of the trainings are described below. Provider Training: Health Homes for Children & Youth Program objectives Participant eligibility Health home services Provider enrollment CRISP Pilot program—lessons learned Health home claims and billing eMedicaid Provider Training: Mental Health Providers Program objectives Participant eligibility Health home services Provider enrollment CRISP Consumer scenarios Health home claims and billing eMedicaid Health Home Accreditation: CARF & The Joint Commission Overview of CARF CARF accreditation standards CARF survey process Overview of The Joint Commission The Joint Commission accreditation requirements The Joint Commission survey process

The state also requires that the behavioral health homes themselves be accredited by either the Commission on Accreditation of Rehabilitation Facilities (CARF) (CARF 2018) or the Joint Commission (2018). This accreditation verifies that minimum standards, detailed in Table 2, are being met by the health home. An initial application for accreditation asks programs to detail information about program structure and service provision. This application is followed by on-site observations and document review by the accrediting agency. Programs that are granted accreditation may be granted one-year, three-year, or provisional accreditation. The program is required to submit scheduled quality improvement plans, detailing program strategies for improvement in response to feedback from the accreditation process and updates to accreditation standards, to the accrediting agency and recertify at the end of the cycle (CARF 2018; Joint Commission 2018).

In addition to submitting these plans to the accrediting agencies, behavioral health homes in Maryland are required to submit evaluations every 6 months to the Maryland Department of Health (COMAR 2018). Reports to the Department of Health include information on service delivery and patient health information and outcomes as well as program assessments demonstrating fulfillment of regulatory requirements and implementation of a quality improvement plan. These evaluations are used by the state to create quarterly reports on the behavioral health homes statewide (Marlyand 2018). The resultant reports are primarily descriptive in nature, and evaluation results are not, currently tied to any financial incentives or accountability efforts.

Also at the regulatory and purchasing agency level, the Code of Maryland Regulations includes program requirements put forth by the Maryland Department of Health (COMAR 2018). Participants must be Medicaid recipients and already receive services from the psychiatric rehabilitation program in which the behavioral health home is located. Behavioral health home enrollment is optional for participants—programs must receive consent of each participant’s willingness to participate. Program eligibility is dependent on meeting the regulations outlined in the Code of Maryland Regulations.

In addition to policies regarding participation, the Maryland Department of Health lays out other policies for behavioral health home program structure and infrastructure (COMAR 2018). One requirement relates to staffing. Maryland requires four positions—health home care manager, health home director, physician or nurse practitioner consultant, and administrative support staff—and outlines specific credentials and full-time employee to consumer ratios for each role. The Department of Health also has requirements related to health information technology. Behavioral health homes are given access to the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange, to receive alerts of hospital admissions and discharges. Additionally, behavioral health homes must register with CRISP or the State’s Administrative Services Organization (ASO) program to receive real-time pharmacy data. Behavioral health homes must also register with eMedicaid, an online portal used by the state to document and bill for Medicaid services. Finally, behavioral health homes must maintain an electronic database with contact and clinical appointment information for consumers; how this database is created is left up to individual program sites.

Additional regulatory agency requirements focus on behavioral health home functions and service delivery (COMAR 2018). The Maryland Department of Health requires behavioral health homes to create internal protocols for reviewing and responding to hospital encounter alerts and pharmacy-use data, lays out communication requirements (e.g., use of health information technology to communicate with patients and other providers), and mandates health home staff meetings at least every 6 months. Participant documentation and care plans, which include consumer goals and progress, must be updated every 6 months. Staff trainings are offered as webinars through the state Department of Health and cover topics including an overview of behavioral health homes, behavioral health home accreditation, and eMedicaid (Maryland 2018).

Reimbursement for Maryland behavioral health homes is a per-member monthly rate of $102.86, contingent on each participant receiving at least two health home services per month (COMAR 2018). The services covered include comprehensive care management (e.g., monitoring and documenting participant health status and progress toward care plan goals), care coordination and health promotion (e.g., delivery of preventive services and education regarding chronic physical health conditions), comprehensive transitional care (e.g., follow up with participants within 2 days of hospital discharge), individual and family support services (e.g., assisting participants with transportation to medically necessary services), and referral to community and social support services (e.g., connecting participants to needed services including medical assistance, subsidized or supportive housing, and legal services).

Organizational Level

At the organizational level, programs implementing behavioral health homes enact their own policies related to population health management software, provider co-location, and staffing (Table 3). Organizations can choose to adopt the state-endorsed software for completing population health management tasks; organizations must purchase the software but the cost of populating it with administrative claims data is covered by the state. Behavioral health home programs make policy decisions regarding how they will facilitate coordination with primary care providers, e.g. the decision to co-locate primary care services at the psychiatric rehabilitation program; the use of contracts or memorandums of agreement (MOUs) with external providers or organizations; or the use of informal partnerships only, where health home providers build relationships with primary care providers in the community. Beyond the staffing requirements laid out by the state of Maryland, organizations can choose to hire additional staff or set added credentialing requirements for behavioral health home staff. Additionally, organizations may shift psychiatric rehabilitation program staff roles to include behavioral health home service delivery.

Table 3.

Policy strategies supporting implementation of Maryland behavioral health homes enacted at the organizational level

Policy strategies	Details
Population health management software	Organizations implementing behavioral health homes can choose to purchase the population health management software endorsed by the state. This software system pulls participant health and pharmaceutical data from eMedicaid for population health management tasks
Coordination with primary care providers	Behavioral health home programs adopt organizational policy strategies related to coordination with primary care providers including: Co-location of services (e.g., primary care provider provides services at the psychiatric rehabilitation program (PRP) location) Formal partnerships with external providers or organizations (e.g., use of a contract or memorandum of agreement) Informal relationships with external providers or organizations (e.g., steering participants to specific primary care providers)
Staffing	Beyond meeting the staffing requirements set by the Maryland Department of Health, behavioral health homes have flexibility in staffing considerations by: Hiring additional behavioral health home staff beyond state requirements Defining credentialing requirements for behavioral health home staff Shifting PRP staff roles to include behavioral health home service delivery

Discussion

The policy ecology of Medicaid behavioral health homes in Maryland includes policies at the legislative, regulatory and purchasing agency, and organizational levels, which are, in turn, impacted by the social context. Despite the implementation of policies across levels of the policy ecology, some of the policies supporting implementation of the Maryland behavioral health homes are not supported by current evidence. Specifically, staffing categories, laid out in both the regulatory and purchasing agency and organizational levels, have been shown to have little effect on program effectiveness in other settings (Burns et al. 2007). Further, three studies (Daumit et al. 2018; Maragakis and RachBeisel 2015; McGinty et al. 2018) have documented barriers to behavioral health home implementation in Maryland, suggesting that changes to the policy ecology may be needed to better support implementation. Five key barriers were identified: (1) challenges coordinating with external providers; (2) inadequate health information technology; (3) lack of population health management capacity; (4) staffing shortfalls; and (5) consumer engagement challenges. These barriers are similar to barriers to behavioral health home implementation in other states (Murphy et al. 2019). While there is not yet an evidence-based policy ecology for implementation of behavioral health homes, additional policies, shown to be successful in other contexts, may be needed to address the barriers to and better support of behavioral health home implementation in Maryland. In the following paragraphs, we briefly summarize the key barriers to behavioral health home implementation identified in three prior studies of Maryland’s program and consider potential changes to the current policy ecology that may help overcome those barriers.

Challenges Coordinating with External Providers

Challenges coordinating with external primary care providers, including lack of incentives for primary care providers to participate in services and negative provider attitudes toward individuals with SMI, were reported by Maryland behavioral health home leaders (Daumit et al. 2018; McGinty et al. 2018). In the existing policy ecology, coordination with external providers is addressed at the organizational level, with each behavioral health home developing their own strategies for primary care coordination. As the entire per-member per-month payment currently goes to the psychiatric rehabilitation program implementing the behavioral health home, changes to policy at the regulatory and purchasing agency level such as enhanced reimbursement rates or other financial incentives may be an effective way to increase external primary care providers’ willingness to coordinate with behavioral health homes (Stewart et al. 2016). Alternative payment models such as a hub-and-spoke model, similar to one used in Vermont’s Medicaid health home program (Clemans-Cope et al. 2017) or an accountable care organization (ACO), similar to that in Massachusetts’s Medicaid Section 1115 wavier (Massachusetts 2018) could create funding streams for both the psychiatric rehabilitation programs implementing the behavioral health homes and the primary care providers in the community with whom they need to coordinate services. Co-located behavioral health home models, in which participants can see a primary care provider onsite at the specialty mental health program implementing the behavioral health home, may also help overcome this barrier. However, extant studies of behavioral health home implementation suggest that co-location is not feasible for all sites (McGinty et al. 2018; Scharf et al. 2013). In Maryland, less than 20% of sites have co-located primary care providers, and those primary care providers are not full-time (e.g., they are onsite 2 days per week); even in the presence of co-location, many consumers at those sites still choose to see an external primary care provider (McGinty et al. 2018).

Inadequate Health Information Technology

The Maryland behavioral health homes have several health information technology systems for accessing participant health information and documentation and billing. However, barriers to effective use of health information technology such as delayed data and lack of interoperability between systems persist. Sites lack effective population health management technology: 27 Maryland behavioral health home sites utilize an elective, state-supported population health management software, but report significant challenges in the software’s usability; and other sites create their own databases for managing participant information (Daumit et al. 2018; McGinty et al. 2018). Sites are supposed to be able to track the services received by participants through the eMedicaid database, but this database’s primary function is billing as opposed to population health management and implementation leaders report that the claims populating the database are often delayed by months, making it impossible to track service receipt in real time (Daumit et al. 2018; McGinty et al. 2018). At the regulatory and purchasing agency level of the policy ecology, financial incentives for health information technology improvements, along the lines of the Medicare and Medicaid Promoting Interoperability Program (CMS 2018b) may serve as a model for encouraging use of specific, interoperable platforms. Policies at the legislative level could also increase the utility of health information technology by addressing issues related to data sharing. One example is North Carolina’s 2015 Health Information Exchange Act, which was designed to promote sharing of health information across healthcare sectors by establishing a state-wide health information exchange and requiring providers who receive Medicaid funding to connect with the exchange (North Carolina 2018). While these policies may help improve health information technology for behavioral health homes in the long term, it may take time for providers to adjust to new programs and workflows (LLuch 2011).

Lack of Population Health Management Capacity

Beyond the health information technology barriers discssued above, additional barriers in Maryland relate to the behavioral health home’s capacity to conduct population health management, a strategy for addressing a continuum of health needs in a population using continuous monitoring and targeted interventions (Struijs et al. 2015). Lack of experience conducting population health management, tension between population health management and direct clinical care, and inflexibility in the Maryland health home service requirements (e.g., requiring two services per member per month for reimbursement) decrease the cacapity of behavioral health homes to conduct this task (Daumit et al. 2018; Maragakis and RachBeisel 2015; McGinty et al. 2018). Currently, the only aspect of the policy ecology meant to facilitate population health management is the software described above—which as noted, has significant usability challenges reported by implementers (Daumit et al. 2018; McGinty et al. 2018). As the goal of population health management is to improve outcomes by targeting high-need individuals, modifying the current regulatory and purchasing agency level reimbursement policy requiring two services per member per month to allow for fewer (or more) services depending on the needs of the specific patient may aid implementation.

Regulatory and purchasing agency level policies that hold behavioral health homes accountable for participant outcomes may also promote population health management by incentivizing focus on the highest need individuals. Such policies may require publishing behavioral health home outcomes in a public manner or providing a financial incentive for meeting performance metrics, such as the ACO model, in which providers share responsibility for meeting quality of care and outcome benchmarks and related financial costs or savings (Shortell et al. 2015), Implementation of ACOs, however, would require buy-in from organizations and providers beyond the behavioral health home and while paying for outcomes is perceived as an effective incentive for adoption of evidence-based practices, the complexity involved may make some stakeholders reluctant to implement this policy (Stewart et al. 2018).

Staffing Shortfalls

Challenges with staff recruitment, retainment, and expertise have been identified as a barrier to behavioral health home implementation in Maryland(Daumit et al. 2018; Maragakis and RachBeisel 2015; McGinty et al. 2018). While staff turnover is a problem in mental health care settings more broadly (Johnson et al. 2018), in the behavioral health home context may be due in part lack of provider experience in performing the care coordination and population health management tasks intrinsic to the health home model. There is some training provided by the state Department of Health through webinars that can be accessed online, but the webinars are not reoccurring (all online material is dated 2013) and there are no state requirements that behavioral health home staff complete the training (Maryland 2018). More intensive training in behavioral health home services may help providers develop the skills needed to effectively deliver services for the complex population with SMI. Development of policies requiring continuing education unit (CEU) or certifications by the regulatory agency or prioritization of staff with these trainings at the organizational level could incentivize participation in trainings.

Consumer Engagement Challenges

Finally, one study of behavioral health home implementation in Maryland identified engaging participants, especially for initial health home enrollment, as a challenge (Maragakis and RachBeisel 2015). Current policy at the legislative and regulatory and purchasing agency levels attempts to maximize participant engagement by targeting a high-need population—individuals with SMI—in the location where they regularly receive care—psychiatric rehabilitation programs. Psychiatric rehabilitation participants may then opt to be enrolled into the behavioral health home, which requires a formal participant consent and enrollment process. To further facilitate participation of consumers in the behavioral health home, switching from the current opt-in policy to an opt-out policy, similar to those used by behavioral health homes in other states, may be beneficial (CMS 2018c).

Many of the challenges impacting implementation of behavioral health homes in Maryland are not unique to either the state or to the behavioral health home setting but are present in implementation of other evidence-based practices more broadly (Aarons et al. 2009; Ubbink et al. 2013). The use of the policy ecology as a framework for analysis emphasizes the importance of looking beyond the intervention itself to consider the complete policy environment. Failing to do so may contribute to misalignment between the goals of the intervention and the resources and infrastructure supporting implementation leaving critical gaps and limiting effectiveness of complex interventions intended to improve access to care and health outcomes for individuals.

Results from this study should be viewed within the context of its limitations. This study only examined the policy ecology of behavioral health homes in Maryland. While it was beyond the scope of this study to compare the policy ecology of Maryland’s Medicaid behavioral health home program to the policy ecology of behavioral health home programs in other states or to quantitatively evaluate the effects of the policies within Maryland’s policy ecology on program implementation and consumer health outcomes, future studies should consider these questions. This study focused on the policy ecology of Maryland behavioral health homes implemented in psychiatric rehabilitation program settings, where the majority (N = 59) of Maryland’s behavioral health homes are implemented. Maryland also implements behavioral health homes in a small number of mobile treatment programs (N = 11) (Maryland 2018). Given the small scope of this program and the fact that the three studies examining barriers to implementation of Maryland’s behavioral health home program focused on psychiatric rehabilitation program settings, we did not consider the policy ecology for behavioral health homes implemented in mobile treatment programs. Mobile treatment programs are a unique setting; behavioral health home implementation in this context likely requires different policy supports than implementation of behavioral health homes in non-mobile contexts.

Further research is needed to rigorously evaluate how the policies we discuss as options for strengthening Maryland’s behavioral health home policy ecology, such as financial incentives for primary care providers and implementing behavioral health homes within ACOs, influence behavioral health home implementation and consumer outcomes.

Conclusion

While Maryland behavioral health homes are currently supported by policies at the organizational, regulatory and purchasing agency, and legislative levels of the policy ecology framework, there remain substantial barriers to effective implementation, documented in three recent studies (Daumit et al. 2018; Maragakis and RachBeisel 2015; McGinty et al. 2018). Modifications to existing polices and additional policies may be needed in order to support effective real-world implementation of behavioral health homes. This case study is a first step toward the identification of a model policy ecology needed to realize the promise of behavioral health homes demonstrated through randomized clinical trials (Druss et al. 2001, 2017).