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Improving Behavioral Health Follow-up Care

Together, Medicaid and Children’s Health Insurance Program (CHIP) are the largest payer of mental health services in the US.1 Almost 40% of adult Medicaid and CHIP beneficiaries under age 65 experience mental illness and/or substance use disorders (SUD).2  Of these beneficiaries, 8% with mental illness and 6% with SUD use inpatient services,3  and 3% and 10% respectively visit emergency departments.4  Research has shown that timely follow-up care for behavioral health-related hospitalizations and emergency department visits is associated with fewer hospital readmissions, increased medication adherence, decreased suicidal ideation.5,6

CMS offers quality improvement (QI) technical assistance (TA) to help states increase access to and use of supports to improve behavioral health follow-up care among individuals enrolled in Medicaid and CHIP.

The TA has two components:

  1. QI resources to help state Medicaid and CHIP staff and their QI partners improve behavioral health follow-up care
  2. CMS’s Improving Behavioral Health Follow-up Care learning collaborative, including approaches to improving behavioral health follow-up care and state examples

For more information on these materials and other QI TA, please email MedicaidCHIPQI@cms.hhs.gov.

QI Resources

These TA resources can help states get started in developing QI projects to improve behavioral health follow-up care:

  • Getting Started on Quality Improvement Video (Coming Soon). This video provides an overview of how Medicaid and CHIP agencies can start a QI project to improve behavioral health follow-up care. The Model for Improvement begins with small tests of change, enabling state teams to “learn their way” toward strong programs and policies.
  • Driver Diagram and Change Idea Table. A driver diagram is a visual display of what “drives” or contributes to improvements in providing behavioral health follow-up care. This example of a driver diagram shows the relationship between the primary drivers (the high-level elements, processes, structures, or norms in the system that must change to improve behavioral health follow-up care) and the secondary drivers (the places, steps in a process, time-bound moments, or norms in which changes are made to spur improvement). The document also includes change idea tables, which provide examples of evidence-based or evidence-informed QI interventions for improving behavioral health follow-up care. The change ideas were tailored for Medicaid and CHIP.
  • Measures for Quality Improvement. This document provides examples of measures that can be used to monitor QI projects focused on improving behavioral health follow-up.

For more information on these materials and other QI technical assistance, please contact MedicaidCHIPQI@cms.hhs.gov

Improving Behavioral Health Follow-up Care learning collaborative

In 2021, CMS facilitated the “Improving Behavioral Health Follow-Up Care” learning collaborative to support state Medicaid and CHIP program efforts to improve access to and coordination of follow-up care for beneficiaries who were hospitalized or who visited an emergency department for a mental health or substance use condition. 

The webinars described strategies states can use to improve behavioral health care access and care coordination.  States interested in acting on the concepts, participated in an action-oriented affinity group, which supported states in designing and implementing their own QI projects. Learnings from participating states can be found in the highlights brief.

Learning Collaborative Webinar Series

  • Expanding and Ensuring Access to Behavioral Health Follow-up Care (video, slides, transcript). This May 2021 webinar focused on the importance of timely and coordinated follow-up care for Medicaid and CHIP beneficiaries discharged from a hospital or emergency department for a behavioral health condition. The Kansas Department for Aging and Disability Services for Behavioral Health Services described how their Medicaid program leveraged telemedicine to reduce psychiatric hospital readmission rates, increase provider capacity, and improve patients’ symptoms and access to care. The Oklahoma Department of Mental Health and Substance Abuse Services presented the state’s health home and integrated care initiatives using clinical and technological innovations integrated with evidence-based practices to increase access to behavioral health care.
  • Leveraging Key Relationships in Improving Behavioral Health Follow-up Care (video, slides, transcript). This June 2021 webinar highlighted the importance of community engagement, specifically among manage care organizations, peer specialists, community providers, and patients. The Virginia Department of Medical Assistance Services presented their value-based purchasing intervention creating a MCO capitation withhold program to incentivize and monitor performance using the HEDIS behavioral health Core Set measures. Speakers from New Jersey Division of Medical Assistance and Health Services presented the state’s peer recovery and care management services intervention supporting individuals with substance use disorders and assists members with care transitions to ensure access to needed services. 
  • Using Data to Improve Access to Behavioral Health Follow-up Care (video, slides, transcript). This July 2021 webinar described how state Medicaid and CHIP agencies can use data to improve access and the quality of behavioral health follow-up care.  Tennessee’s Division of TennCare presented its care coordination tool that includes quality measures and gaps in care, risk scores, admission discharge, and transfer events. Pennsylvania’s Office of Medical Assistance Programs presented how it increased the number of individuals initiating treatment for opioid use disorder within 7 days of an emergency department visit through clinical pathways, warm handoffs, and incentive payments.

1. https://www.medicaid.gov/medicaid/benefits/behavioral-health-services/index.html

2. https://www.kff.org/medicaid/issue-brief/demographics-and-health-insurance-coverage-of-nonelderly-adults-with-mental-illness-and-substance-use-disorders-in-2020/

3. https://www.kff.org/report-section/state-options-for-medicaid-coverage-of-inpatient-behavioral-health-services-report/

4. https://www.medicaid.gov/medicaid/quality-of-care/downloads/improvement-initiatives/behavioral-health-ag-factsheet.pdf

5. https://pubmed.ncbi.nlm.nih.gov/31068399/

6. Beadles, CA; Ellis, AR; LIchstein, JC, et.at. First Outpatient Follow-Up After Psychiatric Hospitalization: Does One Size Fit All? Psychiatric Services 66:4, April 2015; from ps.psychiatryonline.org