Kaiser brief on state adoption of Medicaid options under the ACA: A primary goal of the Affordable Care Act (ACA) is to significantly reduce the number of uninsured Americans through an expansion of Medicaid and the creation of new health insurance exchanges. In addition, the law provides states a range of new opportunities and federal financing alternatives for their Medicaid programs. A new policy brief from the Kaiser Family Foundation's Commission on Medicaid and the Uninsured examines how states in every region have responded to five key opportunities available under the ACA to help them prepare for the significant expansion of Medicaid in 2014. Together these opportunities are leading to changes in the Medicaid program that lay groundwork for the ACA coverage expansions and develop new systems of care for high-cost beneficiaries. The options covered include incentives for states to get an early start on the Medicaid coverage expansion (adopted by eight states as of May 2012), increased federal funding to upgrade Medicaid eligibility systems (adopted by 29 states), special funding for chronic disease prevention (adopted by ten states), money to improve care for beneficiaries with chronic conditions by providing “health home” services (adopted by four states), and help in developing service delivery and payment models that integrate care for beneficiaries who are dually eligible for Medicare and Medicaid (26 states had submitted proposals to test models as of May 2012). Overall, 43 states and the District of Columbia have taken steps forward on at least one of the five options. The 11-page brief is available on the Kaiser Web site at www.kff.org/medicaid/upload/8312.pdf. To help stakeholders understand the terminology being developed to describe the multiplying care delivery and financing models in Medicaid, Kaiser has also released Decoding Medicaid Care Delivery and Financing Models: A Glossary of Widely Used Terms, which is available at www.kff.org/medicaid/upload/8313.pdf.

Kaiser report on state efforts to set up ACOs: An accountable care organization (ACO) is a provider-run organization in which the participating providers are collectively responsible for the care of an enrolled population and also may share in any savings associated with improvements in the quality and efficiency of the care they provide. Several states are actively developing ACO initiatives in an effort to improve the care provided to people through the Medicaid program. A new brief from the Kaiser Commission on Medicaid and the Uninsured that reviews these efforts indicates that most Medicaid ACOs are at an early stage of development, as states engage in relatively lengthy planning and implementation processes in order to accommodate the concerns of various stakeholders and to address state and federal legislative and regulatory requirements. The structure of Medicaid ACO initiatives is influenced by individual states' history and experience with managed care, other existing care delivery arrangements within Medicaid, and the challenges inherent in serving low-income and chronically ill populations. Although Medicaid ACOs are a strategy to more directly engage providers in improving care, cost containment is also an important motivating factor in many states. States must balance short-term cost-containment pressures against the investments in partnerships and delivery system redesign necessary for the success of Medicaid ACOs over the longer term. The 11-page brief is available on the Kaiser Web site at www.kff.org/medicaid/upload/8319.pdf.

VHA announces major hiring initiative: Mounting suicide rates among active-duty soldiers and veterans and possible underdiagnosis of posttraumatic stress disorder have raised serious concerns. In mid-June, Secretary of Veterans Affairs (VA) Eric Shinseki announced that the department would add approximately 1,600 mental health clinicians and nearly 300 support staff to its existing workforce to help meet the increased demand for mental health services. The Veterans Health Administration (VHA) has developed an aggressive national recruitment program to implement the hiring process quickly and efficiently. The program establishes a VHA team of 21 professional recruiters who understand the needs of veterans and who will use private-sector best practices to fill critical clinical and executive positions. VHA has also set up a task force to provide oversight and to report progress in hiring of psychiatrists, psychologists, mental health nurses, social workers, mental health technicians, marriage and family therapists, and licensed professional counselors. VHA aims to select most hires by the end of the year and to hire personnel for the most hard-to-fill positions by June 2013. VA has an existing workforce of 20,590 mental health staff. Information about VA careers and online job applications are available at www.vacareers.va.gov.

New guidelines to manage childhood aggression: Researchers from the Mayo Clinic in collaboration with researchers from other institutions and experts on youth mental health have developed new guidelines for primary care providers and mental health practitioners to manage the common but often complex problem of childhood aggression. Goals include improving diagnosis and care and avoiding inappropriate use of medication. Peter Jensen, M.D., a Mayo Clinic psychiatrist who led the development of the new guidelines, noted that antipsychotics and mood-stabilizing drugs are increasingly prescribed to children to treat overt aggression. “These large-scale shifts in treatment practices have occurred despite potentially troubling side effects and a lack of supportive empirical evidence,” Jensen said. Recommendations include carefully engaging in and forming a strong treatment alliance with the patient and family; conducting a rigorous, thorough diagnostic workup; carefully measuring treatment response and outcomes by using reliable assessment tools; providing education and support for families; helping families obtain community and educational resources; using proven psychologicaltherapies before starting any antipsychotic or mood-stabilizing medications; and carefully tracking (and preventing, whenever possible) side effects. Guideline development was funded by the Agency for Healthcare Research and Quality, the Annie E. Casey Foundation, the REACH Institute, and the states of New York, Texas, and California. The guidelines, “Treatment of Maladaptive Aggression in Youth,” which were published online in the journal Pediatrics, are free and publicly available via a downloadable, user-friendly toolkit (www.thereachinstitute.org/files/documents/t-may-final.pdf).

NAMI Web site aims to mobilize participation in November elections: The National Alliance on Mental Illness (NAMI) has launched a Web site, “Mental Health Care Gets My Vote,” to mobilize individuals and families affected by mental illness to participate in the 2012 elections. “Mental illness does not discriminate. It cuts across all party lines,” said Michael J. Fitzpatrick, executive director of NAMI, which is nonpartisan and does not endorse candidates. The Web site (www.nami.org/elections) provides tools and information, including detailed breakdowns of state election laws and the rights of people living with disabilities. It offers “tip sheets” to encourage individuals and families to ask questions, make statements, and meet and connect with candidates in positive ways, including volunteering on election campaigns. A separate “candidate kit” includes a fact sheet about mental illness and “policy priority briefings” about protecting public mental health services, protecting Medicaid funding and expanding insurance coverage of mental illnesses, and establishing ranges of services and supports for adults and children.

SAMHSA report on trauma-informed care for children: A report released by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that children and adolescents involved in the juvenile justice and child welfare systems had improved outcomes after receiving trauma-informed services. The improvements included reductions in behavioral and emotional problems, trauma symptoms, and substance use problems and improved school, community, and social functioning. The four-page report, Promoting Recovery and Resilience for Children and Youth Involved in Juvenile Justice and Child Welfare Systems, presents data showing that large proportions of children who enter the juvenile justice and child welfare systems have experienced four or more types of traumatic events, such as witnessing or experiencing physical or sexual abuse, violence in families and communities, natural disasters, wartime events and terrorism, accidental or violent death of a loved one, and a life-threatening injury or illness. Trauma-informed services take into account knowledge about how the experience of trauma can affect health and well-being. After receipt of such services, arrests among youths fell significantly and suicide attempts fell from 6% to 1% one year after service entry. Youths also showed significant reductions in symptoms of posttraumatic stress disorder within three months after entering services. After six months, academic problems and behavior problems at home also improved significantly. The report is available on the SAMHSA Web site at www.samhsa.gov/children/samhsa_shortreport_2012.pdf.

HHS Health Innovation Awards go to integrated care programs: The U.S. Department of Health and Human Services Department (HHS) has announced the first 26 organizations to receive Health Care Innovation awards. Made possible by the Affordable Care Act, the awards support innovative projects designed to save money, deliver high-quality care, and enhance the health care workforce. Three of the projects focus on integration of primary and behavioral health care. The Center for Health Care Services in San Antonio, Texas, received an award to integrate care for homeless adults with severe mental illness at risk for chronic physical diseases. The Courage Center, a program in Minneapolis-St. Paul, Minnesota, that serves adults with disabilities and complex medical conditions, received a grant to create a patient-centered medical home focused on the highest-cost Medicaid patients. Funds awarded to Kitsap Mental Health Services in Washington will go toward integrating care for 1,000 adults and children with severe mental illness or emotional disturbance who have at least one comorbid general medical condition. The 26 awards total $122.6 million, and HHS expects them to reduce health spending by $254 million over the next three years. More information about these and the other awardees is on the HHS Web site at innovations.cms.gov/initiatives/innovation-awards/index.html.

CIHS provides billing and financial worksheets for states: Financing is often viewed as a barrier to sustaining activities to integrate primary and behavioral health care. To help programs bill Medicare and Medicaid optimally for integrated services, the Center for Integrated Health Solutions (CIHS) has developed customized billing and financial worksheets for each state that identify existing billing opportunities for services provided in integrated health care settings. In states where the listed codes are not currently reimbursable, the worksheets identify areas where programs can engage state agencies on reimbursement for services provided in integrated settings. State billing and financing worksheets can be downloaded at www.integration.samhsa.gov/financing/billing-tools. An archived Webinar on billing and financing hosted by CIHS is also available (www.integration.samhsa.gov/financing). CIHS is funded jointly by SAMHSA and the Health Resources and Services Administration (HRSA). It was established to promote the development of integrated primary and behavioral health services to better address the needs of individuals with mental health and substance use conditions, whether they are seen in specialty behavioral health or primary care settings.