The Florida Senate

394.9082  Behavioral health service delivery strategies.--

(1)  LEGISLATIVE FINDINGS AND INTENT.--The Legislature finds that a management structure that places the responsibility for mental health and substance abuse treatment services within a single entity and that contains a flexible funding arrangement will allow for customized services to meet individual client needs and will provide incentives for provider agencies to serve persons in the target population who have the most complex treatment and support needs. The Legislature recognizes that in order for the state's publicly funded mental health and substance abuse treatment systems to evolve into a single well-integrated behavioral health system, a transition period is needed and demonstration sites must be established where new ideas and technologies can be tested and critically reviewed.

(2)  DEFINITIONS.--As used in this section, the term:

(a)  "Behavioral health services" means mental health services and substance abuse treatment services that are provided with state and federal funds.

(b)  "Managing entity" means an entity that manages the delivery of behavioral health services.

(3)  SERVICE DELIVERY STRATEGIES.--The Department of Children and Family Services and the Agency for Health Care Administration shall develop service delivery strategies that will improve the coordination, integration, and management of the delivery of mental health and substance abuse treatment services to persons with emotional, mental, or addictive disorders. It is the intent of the Legislature that a well-managed service delivery system will increase access for those in need of care, improve the coordination and continuity of care for vulnerable and high-risk populations, redirect service dollars from restrictive care settings and out-of-date service models to community-based psychiatric rehabilitation services, and reward cost-effective and appropriate care patterns. The Legislature recognizes that the Medicaid, mental health, and substance abuse treatment programs are three separate systems and that each has unique characteristics, including unique requirements for eligibility. To move toward a well-integrated system of behavioral health care services will require careful planning and implementation. It is the intent of the Legislature that the service delivery strategies will be the first phase of transferring the provision and management of mental health and substance abuse treatment services provided by the Department of Children and Family Services and the Medicaid program from traditional fee-for-service and unit-cost contracting methods to risk-sharing arrangements. As used in this section, the term "behavioral health care services" means mental health services and substance abuse treatment services that are provided with state and federal funds.

(4)  CONTRACT FOR SERVICES.--

(a)  The Department of Children and Family Services and the Agency for Health Care Administration may contract for the provision or management of behavioral health services with a managing entity in at least two geographic areas. Both the Department of Children and Family Services and the Agency for Health Care Administration must contract with the same managing entity in any distinct geographic area where the strategy operates. This managing entity shall be accountable at a minimum for the delivery of behavioral health services specified and funded by the department and the agency. The geographic area must be of sufficient size in population and have enough public funds for behavioral health services to allow for flexibility and maximum efficiency. Notwithstanding the provisions of s. 409.912(4)(b)1., at least one service delivery strategy must be in one of the service districts in the catchment area of G. Pierce Wood Memorial Hospital.

(b)  Under one of the service delivery strategies, the Department of Children and Family Services may contract with a prepaid mental health plan that operates under s. 409.912 to be the managing entity. Under this strategy, the Department of Children and Family Services is not required to competitively procure those services and, notwithstanding other provisions of law, may employ prospective payment methodologies that the department finds are necessary to improve client care or institute more efficient practices. The Department of Children and Family Services may employ in its contract any provision of the current prepaid behavioral health care plan authorized under s. 409.912(4)(a) and (b), or any other provision necessary to improve quality, access, continuity, and price. Any contracts under this strategy in Area 6 of the Agency for Health Care Administration or in the prototype region under s. 20.19(7) of the Department of Children and Family Services may be entered with the existing substance abuse treatment provider network if an administrative services organization is part of its network. In Area 6 of the Agency for Health Care Administration or in the prototype region of the Department of Children and Family Services, the Department of Children and Family Services and the Agency for Health Care Administration may employ alternative service delivery and financing methodologies, which may include prospective payment for certain population groups. The population groups that are to be provided these substance abuse services would include at a minimum: individuals and families receiving family safety services; Medicaid-eligible children, adolescents, and adults who are substance-abuse-impaired; or current recipients and persons at risk of needing cash assistance under Florida's welfare reform initiatives.

(c)  Under the second service delivery strategy, the Department of Children and Family Services and the Agency for Health Care Administration shall competitively procure a contract for the management of behavioral health services with a managing entity. The Department of Children and Family Services and the Agency for Health Care Administration may purchase from the managing entity the management services necessary to improve continuity of care and access to care, contain costs, and improve quality of care. The managing entity shall manage and coordinate all publicly funded diagnostic or assessment services, acute care services, rehabilitative services, support services, and continuing care services for persons who meet the financial criteria specified in this part for publicly funded mental health and substance abuse treatment services or for persons who are Medicaid eligible. The managing entity shall be solely accountable for a geographic area and shall coordinate the emergency care system. The managing entity may be a network of existing providers with an administrative services organization that can function independently, may be an administrative services organization that is independent of local provider agencies, or may be an entity of state or local government.

(d)  Under both strategies, the Department of Children and Family Services and the Agency for Health Care Administration may:

1.  Establish benefit packages based on the level of severity of illness and level of client functioning;

2.  Align and integrate procedure codes, standards, or other requirements if it is jointly determined that these actions will simplify or improve client services and efficiencies in service delivery;

3.  Use prepaid per capita and prepaid aggregate fixed-sum payment methodologies;

4.  Modify their current procedure codes to increase clinical flexibility, encourage the use of the most effective interventions, and support rehabilitative activities; and

5.  Establish or develop data management and reporting systems that promote efficient use of data by the service delivery system. Data management and reporting systems must address the management and clinical care needs of the service providers and managing entities and provide information needed by the department for required state and federal reporting. In order to develop and test the application of new data systems, a strategy implementation area is not required to provide information that matches all current statewide reporting requirements if the strategy's data systems include client demographic, admission, discharge, enrollment, service events, performance outcome information, and functional assessment.

(e)  The cost of the managing entity contract shall be funded through a combination of funds from the Department of Children and Family Services and the Agency for Health Care Administration. To operate the managing entity, the Department of Children and Family Services and the Agency for Health Care Administration may not expend more than 10 percent of the annual appropriations for mental health and substance abuse treatment services prorated to the geographic areas and must include all behavioral health Medicaid funds, including psychiatric inpatient funds. This restriction does not apply to a prepaid behavioral health plan that is authorized under s. 409.912(4)(a) and (b).

(f)  Contracting and payment mechanisms for services should promote flexibility and responsiveness and should allow different categorical funds to be combined. The service array should be determined by using needs assessment and best practice models.

(g)  Medicaid contracts for behavioral health overlay services for dependent children or delinquent children will remain fee-for-service. Any provider who currently contracts to provide Medicaid behavioral health services with residential group care facilities under the Family Safety program of the Department of Children and Family Services or with the Department of Juvenile Justice to serve delinquent youth in residential commitment programs shall be included in the network of providers in both service delivery strategies and shall continue the existing staffing arrangements. During the operation of the service delivery strategies, any new behavioral health provider that enters into a contract with residential group care facilities under the Family Safety program of the Department of Children and Family Services or with the Department of Juvenile Justice for delinquent youth in residential commitment programs shall also be included in the network.

(5)  STATEWIDE ACTIONS.--The agency and the department shall jointly develop and implement strategies that reduce service costs in a manner that mitigates the impact on persons in need of those services. The agency and department may employ any methodologies on a regional or statewide basis necessary to achieve the reduction, including but not limited to use of case rates, prepaid per capita contracts, utilization management, expanded use of care management, use of waivers from the Centers for Medicare and Medicaid Services to maximize federal matching of current local and state funding, modification or creation of additional procedure codes, and certification of match or other management techniques. The department may contract with a single managing entity or provider network that shall be responsible for delivering state-funded mental health and substance abuse services. Any not-for-profit agency providing Medicaid reimbursed mental health or substance abuse services to dependent children as of May 1, 2003, shall be included in the network. The managing entity shall coordinate its delivery of mental health and substance abuse services with all prepaid mental health plans in the region or the district. The department may include in its contract with the managing entity data-management and data-reporting requirements, clinical program management, and administrative functions. Before the department contracts for these functions with the provider network, the department shall determine that the entity has the capacity and capability to assume these functions. The roles and responsibilities of each party must be clearly delineated in the contract.

(6)  GOALS.--The goal of the service delivery strategies is to provide a design for an effective coordination, integration, and management approach for delivering effective behavioral health services to persons who are experiencing a mental health or substance abuse crisis, who have a disabling mental illness or substance abuse disorder and will require extended services in order to recover from their illness, or who need brief treatment or supportive interventions to avoid a crisis or disability. Other goals of the models include the following:

(a)  Improve accountability for a local system of behavioral health care services to meet performance outcomes and standards.

(b)  Assure continuity of care for all children, adolescents, and adults who enter the publicly funded behavioral health service system.

(c)  Provide early diagnosis and treatment interventions to enhance recovery and prevent hospitalization.

(d)  Improve assessment of local needs for behavioral health services.

(e)  Improve the overall quality of behavioral health services through the use of best practice models.

(f)  Demonstrate improved service integration between behavioral health programs and other programs, such as vocational rehabilitation, education, child welfare, primary health care, emergency services, and criminal justice.

(g)  Provide for additional testing of creative and flexible strategies for financing behavioral health services to enhance individualized treatment and support services.

(h)  Control the costs of services without sacrificing quality of care.

(i)  Coordinate the admissions and discharges from state mental health hospitals and residential treatment centers.

(j)  Improve the integration, accessibility, and dissemination of behavioral health data for planning and monitoring purposes.

(k)  Promote specialized behavioral health services to residents of assisted living facilities.

(l)  Reduce the admissions and the length of stay for dependent children in residential treatment centers.

(m)  Provide services to abused and neglected children and their families as indicated in court-ordered case plans.

(7)  ESSENTIAL ELEMENTS.--

(a)  The managing entity must demonstrate the ability of its network of providers to comply with the pertinent provisions of this chapter and chapter 397 and to assure the provision of comprehensive behavioral health services. The network of providers shall include, but is not limited to, mental health centers, substance abuse treatment providers, hospitals, licensed psychiatrists, licensed psychiatric nurses, and mental health professionals licensed under chapter 490 or chapter 491. A behavioral health client served by the network under the service delivery strategies may reside in his or her own home or in settings including, but not limited to, assisted living facilities, skilled nursing facilities, foster homes, or group homes.

(b)  The target population to be served in the service delivery strategies must include children, adolescents, and adults who fall into the following categories:

1.  Adults in mental health crisis;

2.  Older adults in crisis;

3.  Adults with serious and persistent mental illness;

4.  Adults with substance abuse problems;

5.  Adults with forensic involvement;

6.  Older adults with severe and persistent mental illness;

7.  Older adults with substance abuse problems;

8.  Children and adolescents with serious emotional disturbances as defined in s. 394.492(6);

9.  Children with substance abuse problems as defined in s. 397.93(2);

10.  Children and adolescents in state custody pursuant to chapter 39; and

11.  Children and adolescents in residential commitment programs of the Department of Juvenile Justice pursuant to chapter 985.

(c)  The service delivery strategies must include a continuing care system for persons whose clinical and functional status indicates the need for these services. These persons will be eligible for a range of treatment, rehabilitative, and support services until they no longer need the services to maintain or improve their level of functioning. Given the long-term nature of some mental and addictive disorders, continuing care services should be sensitive to the variable needs of individuals across time and shall be designed to help assure easy access for persons with these long-term problems. The Department of Children and Family Services shall develop criteria for the continuing care program for behavioral health services.

(d)  A local body or group must be identified by the district administrator of the Department of Children and Family Services to serve in an advisory capacity to the behavioral health service delivery strategy and must include representatives of the local school system, the judicial system, county government, public and private Baker Act receiving facilities, and law enforcement agencies; a consumer of the public behavioral health system; and a family member of a consumer of the publicly funded system. This advisory body may be the community alliance established under s. 20.19(6) or any other suitable established local group.

(e)  The managing entity shall ensure that written cooperative agreements are developed among the judicial system, the criminal justice system, and the local behavioral health providers in the geographic area which define strategies and alternatives for diverting, from the criminal justice system to the civil system as provided under part I of this chapter or chapter 397, persons with behavioral health problems who are arrested for a misdemeanor. These agreements must also address the provision of appropriate services to persons with behavioral health problems who leave the criminal justice system.

(f)  Managing entities must submit data to the Department of Children and Family Services and the Agency for Health Care Administration on the use of services and the outcomes for all enrolled clients. Managing entities must meet performance standards developed by the Agency for Health Care Administration and the Department of Children and Family Services related to:

1.  The rate at which individuals in the community receive services, including persons who receive followup care after emergencies.

2.  Clinical improvement of individuals served, clinically and functionally.

3.  Reduction of jail admissions.

4.  Consumer and family satisfaction.

5.  Satisfaction of key community constituents such as law enforcement agencies, juvenile justice agencies, the courts, the schools, local government entities, and others as appropriate for the locality.

(g)  The Agency for Health Care Administration may establish a certified match program, which must be voluntary. Under a certified match program, reimbursement is limited to the federal Medicaid share to Medicaid-enrolled strategy participants. The agency shall take no action to implement a certified match program without ensuring that the consultation provisions of chapter 216 have been met. The agency may seek federal waivers that are necessary to implement the behavioral health service delivery strategies.

(h)1.  The Department of Children and Family Services, in consultation with the Agency for Health Care Administration, shall prepare an amendment by October 31, 2001, to the 2001 master state plan required under s. 394.75(1), which describes each service delivery strategy, including at least the following details:

a.  Operational design;

b.  Counties or service districts included in each strategy;

c.  Expected outcomes; and

d.  Timeframes.

2.  The amendment shall specifically address the application of each service delivery strategy to substance abuse services, including:

a.  The development of substance abuse service protocols;

b.  Credentialing requirements for substance abuse services; and

c.  The development of new service models for individuals with co-occurring mental health and substance abuse disorders.

3.  The amendment must specifically address the application of each service delivery strategy to the child welfare system, including:

a.  The development of service models that support working with both children and their families in a community-based care system and that are specific to the child welfare system.

b.  A process for providing services to abused and neglected children and their families as indicated in court-ordered case plans.

(8)  EXPANSION IN DISTRICTS 4 AND 12.--The department shall work with community agencies to establish a single managing entity for districts 4 and 12 accountable for the delivery of substance abuse services to child protective services recipients in the two districts. The purpose of this strategy is to enhance the coordination of substance abuse services with community-based care agencies and the department. The department shall work with affected stakeholders to develop and implement a plan that allows the phase-in of services beginning with the delivery of substance abuse services, with phase-in of subsequent substance abuse services agreed upon by the managing entity and authorized by the department, providing the necessary technical assistance to assure provider and district readiness for implementation. When a single managing entity is established and meets readiness requirements, the department may enter into a noncompetitive contract with the entity. The department shall maintain detailed information on the methodology used for selection and a justification for the selection. Performance objectives shall be developed which ensure that services that are delivered directly affect and complement the child's permanency plan. During the initial planning and implementation phase of this project, the requirements in subsections (6) and (7) are waived. Considering the critical substance abuse problems experienced by many families in the child protection system, the department shall initiate the implementation of the substance abuse delivery component of this program without delay and furnish status reports to the appropriate substantive committees of the Senate and the House of Representatives no later than February 29, 2004, and February 28, 2005. The integration of all services agreed upon by the managing entity and authorized by the department must be completed within 2 years after project initiation. Ongoing monitoring and evaluation of this strategy shall be conducted in accordance with subsection (9).

(9)  MONITORING AND EVALUATION.--The Department of Children and Family Services and the Agency for Health Care Administration shall provide routine monitoring and oversight of and technical assistance to the managing entities. The Louis de la Parte Florida Mental Health Institute shall conduct an ongoing formative evaluation of each strategy to identify the most effective methods and techniques used to manage, integrate, and deliver behavioral health services. The entity conducting the evaluation shall report to the Department of Children and Family Services, the Agency for Health Care Administration, the Executive Office of the Governor, and the Legislature every 12 months regarding the status of the implementation of the service delivery strategies. The report must include a summary of activities that have occurred during the past 12 months of implementation and any problems or obstacles that have in the past, or may in the future, prevent the managing entity from achieving performance goals. The first status report is due January 1, 2002. After the service delivery strategies have been operational for 1 year, the status report must include an analysis of administrative costs and the status of the achievement of performance outcomes. By December 31, 2006, the Louis de la Parte Florida Mental Health Institute, as a part of the ongoing formative evaluation of each strategy, must conduct a study of the strategies established in districts 1, 8, 4, and 12 under this section, and must include an assessment of best practice models in other states. The study must address programmatic outcomes that include, but are not limited to, timeliness of service delivery, effectiveness of treatment services, cost-effectiveness of selected models, and customer satisfaction with services. Based upon the results of this study, the department and the Agency for Health Care Administration, in consultation with the managing entities, must provide a report to the Executive Office of the Governor, the President of the Senate, and the Speaker of the House of Representatives. This report must contain recommendations for the statewide implementation of successful strategies, including any modifications to the strategies, the identification and prioritization of strategies to be implemented, and timeframes for statewide completion that include target dates to complete milestones as well as a date for full statewide implementation.

History.--s. 9, ch. 2001-191; s. 8, ch. 2003-279; s. 42, ch. 2004-5; s. 17, ch. 2004-344.