Attachment 11f Implementation Interview Protocol with Instructions

Attachment 1.f. SMI/SED Demonstration Implementation Interview Protocol with Instructions

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148 (CMS-10398 # 59). The time required to complete this information collection is estimated to average 60 minutes to participate in this interview. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.”

Your decision to participate in this aspect of the study is voluntary. Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of the law. If you do not wish to participate in this interview or answer specific questions, please let us know. We believe there are minimal risks to you from participation, and every effort will be made to protect your confidentiality. In reports to CMS, we will refer to you anonymously as a “state officials”

Your insights on the section 1115 SMI/SED waivers (or demonstrations) are important and will be used by federal and state policymakers as well as other Medicaid programs in improving Medicaid mental health services and developing resources and supports for states implementing SMI/SED demonstrations.

Finally, we would like to record our conversation, to ensure our notes from today are complete. Do I have your permission to audio record our conversation today? Do you have any questions before we begin?

INTRODUCTIONS

Good [MORNING/AFTERNOON], my name is [LEAD INTERVIWER] from RTI International. I will be leading the interview today. Also on the call are [SUPPORTING ANALYSTS] who will be taking notes.

As a reminder, this interview will last 60 minutes.  The interview will be in-depth discussion of implementation experience, challenges, and programmatic changes for Medicaid beneficiaries in support of the section 1115 SMI/SED demonstration.

We would like to know how those state-level changes affected delivery of services for Medicaid enrollees with SMI or SED. For each topic, we will ask what changes [STATE] implemented as part of the demonstration, the challenges you encountered, and any observed impact on providers and Medicaid enrollees.

Would you like to introduce yourselves and your role in the organization?

Overall Perspectives on the Section 1115 SMI/SED Demonstration

To get us started, I would like to start with some high-level questions about SMI/SED treatment services in [State] and your SMI demonstration.

1. To start, we would like to confirm a few dates with you:

   1. [STATE]’s SMI demonstration was approved [INSERT DEMONSTRATION APPROVAL DATE]. Is this the date you began drawing federal financial participation (FFP) for IMD stays? If not, when did you start drawing FFP? When did you begin other demonstration-related activities?

2. From your perspective, what was the motivation for pursuing the SMI/SED section 1115 demonstration?

   1. PROBE: Where were the biggest gaps in service delivery or coverage prior to the demonstration (e.g., gaps in community-based care or crisis care for Medicaid enrollees with SMI/SED)?

Note to interviewer: only provide the examples if someone needs them.

3. From your perspective, what are the most important activities [STATE] is doing under the demonstration?

4. Which demonstration activities do you think are most likely to have the greatest impact on Medicaid enrollees with SMI or SED and why?

   1. PROBES: Improved access to IMD services? Crisis services? Community-based services? Integrated primary and behavioral health care? Integration with social services? Improved access to mental health care for youth? Any state reported changes in provider reimbursement for treatment?

   2. PROBE: Have you already noticed an impact? How so?

5. Are there other changes the state is making outside the demonstration that you expect to have significant impact on Medicaid enrollees with SMI or SED? What are they?

Insert prompts with state activities that we already know about and that may be relevant.

1. PROBE: Were any of these activities funded with grants or state-only funds?

1. [For states that also have a section 1115 SUD demonstration] Your state also has a section 1115 substance use disorder (SUD) demonstration. Do you coordinate activities between the SMI and the SUD demonstration? If yes, how so?

   1. PROBE: What challenges have you faced in coordinating efforts? How have you dealt with the challenges?

Milestone 1: Ensuring Quality of Care in Psychiatric Hospitals and Residential Settings

7. Have any of your state’s regulations, licensing criteria, or utilization review policies for SMI residential providers changed because of the demonstration? If so, how? For example, do you have any new types of residential providers for the SMI or SED that you do not have for the SUD population? Did you put new requirements in place for residential providers serving SMI/SED patients that are not needed for residential providers serving SUD patients.

   1. PROBE: Can you talk about provider feedback on the new standards?

   2. PROBE: Did the COVID-19 public health emergency change anything you had put in place? Do you plan to keep any of the COVID-19 related changes going forward?

   3. PROBE: Are there any challenges have you faced changing regulations or policies? What are they, and how are you dealing with them?

8. What was the patient assessment tool used to determined appropriate length of stay or level care in a residential or inpatient setting prior to the demonstration? Did this change with the implementation of the demonstration?

   1. PROBE: Are there any challenges have you faced concerning patient assessment tools? What are they, and how are you dealing with them?

Milestone 2: Improving Care Coordination and Transitions to Community-Based Care

9. As part of the demonstration, did you make any changes:

1. to help providers coordinate mental health care and physical health care for Medicaid enrollees with SMI or SED? If yes, please describe those changes and current strategies to improve coordination.

   1. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current strategies differ for individuals enrolled in fee-for-service Medicaid and individuals enrolled in Medicaid managed care? How so?

   2. PROBE: What has been the impact of these changes?

   3. PROBE: Are there any challenges that you face implementing care coordination activities through the demonstration? What are they, and how are you dealing with them?

   4. PROBE: Were there any facilitators that support coordination?

2. to help providers coordinate with SUD services? If yes, please describe those changes and current strategies to improve coordination.

   1. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current strategies differ for individuals enrolled in fee-for-service Medicaid and individuals enrolled in Medicaid managed care? How so?

   2. PROBE: What has been the impact of these changes?

   3. PROBE: Are there any challenges that you face implementing care coordination activities through the demonstration? What are they, and how are you dealing with them?

   4. PROBE: Were there any facilitators that support coordination?

3. to help residential or inpatient providers coordinate with community-based mental health treatment providers? If yes, please describe those changes and current strategies to improve coordination.

   1. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current strategies differ for individuals enrolled in fee-for-service Medicaid and individuals enrolled in Medicaid managed care? How so?

   2. PROBE: What has been the impact of these changes?

   3. PROBE: Are there any challenges that you face implementing care coordination activities through the demonstration? What are they, and how are you dealing with them?

   4. PROBE: Were there any facilitators that support coordination?

10. As part of the demonstration, did you make any changes to help providers coordinate with social service providers like housing agencies or organizations providing supportive employment and education services? If yes, please describe those changes and current strategies to improve coordination?

Insert prompts for state related activities that we already know about; e.g. housing assessments and referrals, supportive employment pilot

1. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current strategies differ for individuals enrolled in fee-for-service Medicaid and individuals enrolled in Medicaid managed care? How so?

2. PROBE: Are there any challenges that you face implementing care coordination activities through the demonstration? What are they, and how are you dealing with them?

3. PROBE: Were there any facilitators that support coordination?

11. How has SMI/SED treatment and service availability changed with the demonstration?

    1. PROBE: Has there been any change in treatment availability for youth?

PROBE: Have you seen an increase in treatment among SMI/SED patients since the implementation of the demonstration?

12. How is the state leveraging health IT to improve care coordination for Medicaid enrollees with SMI or SED?

Insert prompts for state related activities that we already know about; e.g., electronic care plans, and electronic transitions of care documents, advance care coordination, alert providers to patients at risk for discontinuing engagement in mental health treatment

13. How has the COVID-19 pandemic impacted care coordination changes you made or had planned to make?

14. Were there any other changes to your state’s approach to care coordination you would like to discuss? If yes, can you describe those other changes?

Milestone 3: Increasing Access to Continuum of Care Including Crisis Stabilization Services

15. Are there any changes to crisis stabilization services for:

1. adults that are being implemented as part of the demonstration? If yes, please describe those changes.

2. children and adolescents that are being implemented as part of the demonstration? If yes, please describe those changes.

3. other vulnerable populations that are being implemented as part of the demonstration? If yes, please describe those changes.

Insert prompts for crisis service activities that we already know about; e.g., pilots for youth or justice-involved individuals

1. PROBE: [If the state has managed care and fee-for-service] If yes, did changes and current strategies differ for individuals enrolled in fee-for-service Medicaid and individuals enrolled in Medicaid managed care? How so?

2. PROBE: What has been the impact of these changes?

1. PROBE: Are there any challenges that you face implementing crisis services through the demonstration? What are they, and how are you dealing with them?

1. PROBE: Were there any facilitators that support coordination?

1. How does [STATE] track available mental health inpatient and crisis stabilization beds?

   1. PROBE: Is this different from what you were doing before the demonstration? How so?

1. PROBE: Are there any challenges that you face monitoring bed availability? What are they, and how are you dealing with them?

1. PROBE: Were there any facilitators that helped your efforts to monitor available beds?

1. Do you expect the number of Medicaid enrollees with SMI receiving crisis services to change because of the demonstration? Why or why not? Do you expect the number of Medicaid enrollees with SED receiving crisis services to change because of the demonstration? How so?

2. How has COVID-19 impacted availability of mental health services, including crisis services, for [STATE’s] Medicaid enrollees with SMI or SED?

   1. PROBE: How has [State] utilized telehealth services for the SMI/SED population?

Milestone 4: Early Identification and Engagement in Treatment

19. What did early identification of SMI for SED for Medicaid enrollees look like prior to the demonstration? What has changed with implementation of the demonstration?

    1. PROBE: Were the early identification strategies different for adults vs. children?

2. PROBE: Are there any challenges that you face trying to help providers identify mental health conditions earlier? What are they, and how are you dealing with them?

3. PROBE: Were there any facilitators that support early identification?

20. How has COVID-19 impacted the early identification activities you made or had planned to make?

21. Longer-term patient engagement in treatment and loss to follow-up is a common issue. Are there any changes [STATE] is making as part of the demonstration to support providers in retaining patients with SMI or SED in treatment? If yes, please describe those changes.

    1. PROBE: Is the [STATE] focused on particular populations (e.g., children, other vulnerable groups) when trying out strategies to support retention in treatment?

    2. PROBE: Are there any challenges that you face trying to help providers engage and retain patients? What are they, and how are you dealing with them?

    3. PROBE: If no challenges, were there any facilitators that support early identification?

22. How has COVID-19 impacted patient engagement activities you made or had planned to make?

23. Have specialized behavioral health services particularly for children and adolescents changed under the demonstration? What was offered before, and what is offered now?

Insert prompts for state activities related to children and adolescents with SED that we already know about and that may be relevant

1. PROBE: Are there any challenges that you face trying to deliver services to children with SED? What are they, and how are you dealing with them?

2. PROBE: If no challenges, were there any facilitators that support service delivery for children?

Other Successes or Challenges

24. Are there other implementation challenges or successes under the section 1115 SMI/SED demonstration that we have not yet discussed you would like to mention?

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