deBy: Patrick Kanary, Consultant
OhioRISE[1] (Resilience through Integrated Systems and Excellence) is Ohio’s new Medicaid Managed Care behavioral health program for children and youth with serious and complex behavioral health needs, and their families. Aetna Better Health of Ohio[2] is the managed care provider for OhioRISE. OhioRISE went ‘live’ on July 1, 2022.
The Need for a Better System
Qualitative and quantitative data clearly show that needs of youth with serious and complex behavioral health frequently transcend our public systems’ boundaries. The needs of multi-system youth (MSY) are complex and often involve the behavioral health, child protection, education, developmental disabilities, and juvenile justice systems. The portals for entry into the child serving systems are many and the experiences of youth and families varies widely across the state.
The needs of multi-system youth (MSY) are complex and often involve the behavioral health, child protection, education, developmental disabilities, and juvenile justice systems.
Ohio has long worked to meet the serious and complex behavioral health needs of children, youth, and their families. Previous (and ongoing) efforts to move this work forward have included state and local system of care grants, Family and Children First initiatives[3], local intersystem collaborations, advocacy to fund multisystem youth[4], the state’s current multi-system youth custody relinquishment prevention program, and many other efforts
However, despite these achievements, there remain gaps to fill, access to achieve, and services to provide. OhioRISE enters this landscape with the tools and resources to move the system to the next level, including a new waiver to prevent custody relinquishment in order to access services[5].
Ohio Rise’s approach for eligible youth and family’s is to focus on need, regardless of the system(s) with which they may be involved.
OhioRise’s approach for eligible youth and family’s is to focus on need, regardless of the system(s) with which they may be involved. To help achieve this, Care Management Entities (CMEs) were created to be region accountable organizations that can serve as a coordinated focal point of entry into the behavioral health system with the capacity to coordinate, facilitate, and monitor individualized care plans as directed by families and youth and their team.
What Will CMEs Do?
A key element of this new approach is the creation and implementation of Care Management Entities[6] (CMEs). As described in the CME Manual:[7]
OhioRISE Care Management Entities (CME) in Ohio are responsible for coordinating supports and services for youth with moderate and high needs, as well as their families, to help navigate multiple complex systems. CMEs are responsible for removing barriers to care and supporting the development of a sustainable long-term plan that allows youth and families to succeed. CMEs help with behavioral health care needs by coordinating and accessing supports and services that line up with the identified goals of the youth and family.
According to the Ohio Department of Medicaid (ODM) CMEs ‘will serve as the go-to providers delivering wraparound care coordination for children and youth enrolled in OhioRISE who have the most complex behavioral health needs. CMEs will also help ground and grow their communities’ system of care so overall resources expand to help kids with behavioral health needs and their families in the coming months and years.’
Who Are the CMEs?
As the result of a competitive application process, 20 community-based organizations were selected to fulfill this role. These selected organizations together will cover all of Ohio’s 88 counties (see list, map, AND faq)[8].
Several pillars support the roles of CMEs including ODM and its partnering state agencies; Aetna Better Health of Ohio; community providers; local system of care members; and the Child and Adolescent Behavioral Health Center of Excellence (the technical assistance provider[9]). The COE is located at the Begun Center at Case Western Reserve University, and provides readiness reviews, staff training, technical assistance, fidelity monitoring and consultation to the CMEs and service providers. This support includes training in Wraparound, select best practices as identified in OhioRISE[10], and the Child and Adolescent Needs and Strength tool.[11]
How Do the CMEs Operate?
To identify and address these needs, there are several components to the role of CMEs. The community-based CME organizations subcontract with Aetna to provide the care coordination services, duties and responsibilities as stipulated under the OhioRISE contract[12]. CME Care Coordinators will be responsible for providing Tiers two and three.
- Tier 3 is Intensive Care Coordination (caseload of 1:10) which follows the High-Fidelity Wraparound model[13] and relies on creative and innovative approaches to services and supports for the youth requiring the highest level of
- Tier 2 is Moderate Care Coordination (caseload of 1:25) which will use Wraparound informed approaches to expand/enhance the network of providers, supports, and team members.
- Tier 1 is Limited Care Coordination (caseload of 1:62) provided by Aetna staff, for youth and families for whom only a lower intensity level of coordination is needed.[Presently not all covered services exist in equitable distribution across the state and so part of the heavy lift of CMEs is to work to increase access and availability. The CMEs are not only a resource to youth and families but also to their sister agencies, state partners, and collaborators in assessing and improving the local system of care.
The CMEs are not only a resource to youth and families but also to their sister agencies, state partners, and collaborators in assessing and improving the local system of care.
Just as CMEs will facilitate creating local care teams in partnership with families, there is also a team in place at the state level to oversee the bigger picture. ODM provides the state and federal regulatory responsibility for implementing Ohio’s federally approved Medicaid plans. Aetna, as the contract holder for the OhioRISE component of Medicaid, oversees the overall performance of the CMEs per their contracts, and the COE is responsible for the support, training, fidelity monitoring, and education needs of the CMEs as they grow and develop. Working in collaboration with these entities are Governor DeWine’s Family and Children First Children’s Cabinet members, statewide professional associations, family and youth advocates and a host of other interested parties who are invested in Ohio’s kids and families. OhioRISE is also partnering with the Department of Job and Family Services (JFS) to implement the child protection systems’ Family First Pres Services Act (FFPSA). This initiative focuses on implementing evidence-based practices designed to reduce out of home placement of youth.
Implementation of CMEs
Following the selection of the CMEs, staff on-boarding and training began. ODM has provided nearly $20 million in startup and work force development funds for CMEs. Each CME has participated in a ‘readiness review’ by the COE and each have an individual development plan to address as they get up and running. While some CMEs have considerable experience with some elements of the requirements, for others this will include more education and training. What does appear to be consistent across CMEs is the willingness to become part of OhioRISE and embrace its ideals and vision. Even before going live on July 1, CMEs have been engaging with their community partners and networking among themselves.
On day one of OhioRISE about 5,000 pre-identified youth and their families will enter the plan.
Given the anticipation of an improved system of care under OhioRISE, it’s possible to underestimate the time and effort it will take to be fully operational. On day one of OhioRISE about 5,000 pre-identified youth and their families will enter the plan. The longer-range goal is that by the end of year one each CME will be serving between 1,500-3,000 youth and their families. Implementation science tells us that it may take years for service and system redesign to be achieved. The blueprint for OhioRISE requires multiple moving parts to fit together. Adjustments will be made. Refinements will occur. The design may likely be improved upon over time, but the ground has been broken and the building has started.
[1] https://managedcare.medicaid.ohio.gov/managed-care/ohiorise/ohiorise https://managedcare.medicaid.ohio.gov/wps/wcm/connect/gov/170888a7-7938-43c0-9ada-14a3a192a99e/DRAFT%5FODM+Next+Gen%5FFact+Sheet+OhioRISE%5F06022022.pdf?MOD=AJPERES&CVID=o4BkfV6
[2] https://www.aetnabetterhealth.com/ohiorise/index.html
[4] https://comsolutionst.wpengine.com/collaborations/multi-system-youth-coalition/
[5] OhioRISE will utilize a new 1915(c) waiver to target the most in need and vulnerable families and children to keep families together.
[6] https://managedcare.medicaid.ohio.gov/managed-care/ohiorise/5-OhioRISE+CMEs
[7] https://managedcare.medicaid.ohio.gov/wps/wcm/connect/gov/5a41372d-db3f-451e-a29f-4275572cc1d2/OHR+CME+Manual.pdf?MOD=AJPERES&CVID=o3YTEQW
[8] https://managedcare.medicaid.ohio.gov/wps/wcm/connect/gov/fad0497a-3292-43fc-abc7-8df32ba0c3f6/Slide1.PNG?MOD=AJPERES&CVID=o0YUWBC
[9] https://comsolutionst.wpengine.com/child-adolescent-behavioral-health-center-excellence/
[10] https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/ohio-rise/pdf/abhohiorise%5Fquick%5Freference%5Fguide.pdf
[11] https://praedfoundation.org/tcom/tcom-tools/the-child-and-adolescent-needs-and-strengths-cans/
[12] https://managedcare.medicaid.ohio.gov/wps/wcm/connect/gov/218bc9bb-34e6-4913-9551-f7fc9aaa7e89/OhioRISE+Provider+Agreement%5F6-29-21.pdf?MOD=AJPERES&CVID=nGHQBVA
[13] https://wraparoundohio.org
[i] 4/27/21 Stakeholder Webinar: The Ohio Department of Mental Health and Addiction Services (OhioMHAS), in conjunction with the Departments of Job and Family Services, Medicaid, Youth Services, Developmental Disabilities, and Health and Ohio Family and Children First, issued an RFP to develop and implement a Child and Adolescent Behavioral Health Center of Excellence (CABH COE). https://comsolutionst.wpengine.com/child-adolescent-behavioral-health-center-excellence/
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