Designing Care Management Entities for Youth with Complex Behavioral Health Needs

The CME design process is a creative, complex effort that requires careful consideration of how a State could structure a CME. Depending on a State’s readiness for implementation, the CME design process can take between 1 and 3 years or more (use Part 2 of this guide to assess State readiness).

As indicated in Figure 1, States can use the three strategies highlighted in this section to help prepare for CME design activities and to think through important CME design decisions. States can apply each strategy outlined here to help prepare for CME implementation and to facilitate design of the seven CME design features listed in the center of Figure 1 and described in more detail in Part 4. Throughout the Guide, please refer to the side bar for additional resources on CME design and implementation.

Figure 1: Thinking Through CME Program Design—Strategies to Use and Features to Consider in CME design

Strategy 1: Work with Stakeholders

Broad stakeholder involvement is critical because CMEs require cross-agency coordination and extensive youth, family, and provider involvement to operate effectively and enhance outcomes. Stakeholders should be involved in all of the design decisions.

Selecting and Engaging Stakeholders

This section provides guidance on how States should engage stakeholders in the CME design process.

Form Collaborative Cross-Agency Partnerships

States should invite agencies representing Medicaid, child welfare, behavioral health services, juvenile justice, social services, and education to collaborate on the CME design process. Cross-agency partnerships are imperative when multiple agencies are contributing funding to the CME. States should also consider fostering partnerships with non-funding agencies, since local agency staff (such as behavioral health providers, social workers, probation officers, and educators) should be invited to participate in care planning meetings regardless of who funds the CME services.

For each agency, States should consider recruiting:

• High-level decisionmakers whose buy-in and approval are needed for key design decisions such as: (1) what services the agency is interested in having CMEs coordinate and (2) the level of funding agencies contribute to CMEs.
• Program staff at State and local agencies who can help determine which youth the CME should serve and ensure the CME fits into the local service delivery environment.

Engage Other Stakeholders

The participating agencies should also involve the following stakeholder groups in CME design discussions:

• Youth and families. Input from youth and their families can help a State understand how a CME could improve the existing service system from a consumer’s point of view.
• Provider community. Behavioral and physical health providers, social service providers, court representatives, and others who work closely with youth can provide unique insight into how services are currently structured and paid for and how to improve service delivery. These groups can also help a State avoid potential pitfalls in CME design that might reduce provider acceptance of the model and limit referrals.

Utilization management organizations. Include organizations that work with agencies to authorize, oversee, or finance behavioral health or social services for youth, including Medicaid Managed Care Organizations. These groups can provide insight on improving care delivery. In addition, engaging utilization management organizations in the design process can facilitate a productive working relationship between them and the CME once it is operational.

Strategies for Working with Stakeholders

States can encourage continuous stakeholder participation by:

• Educating stakeholders on CME goals and outcomes. States will need to provide basic information at the beginning of the stakeholder engagement process to build shared understanding about CMEs, especially if high fidelity wraparound is a new concept in the State. Stakeholder education throughout the process helps integrate new stakeholders and minimize disruption.
• Giving voice to all stakeholders. The State can foster constructive input from all parties by recognizing different stakeholder perspectives.
  • Strategies for child-serving agencies. Participating agencies can select a neutral organization to convene cross-agency meetings as one means to ensure that design decisions are not dominated by one agency, which could prompt other agencies to disengage from the process.
  • Strategies for youth and families. Youth and families in particular should feel that their inclusion in the CME design process is more than a token gesture. Strategies for engaging youth and families include hosting youth and parent conferences, conducting focus groups, and covering child care and travel expenses so a family representative can attend all stakeholder meetings as a core team member.

For more information on stakeholder engagement, consult the first implementation guide in this series: Engaging Stakeholders to Improve the Quality of Children’s Health Care.²⁷

Strategy 2: Consult CME Experts

For help deciding among the complex array of CME design options, States could consult either with other States that have implemented a CME or with organizations that provide technical assistance in CME design and implementation. As with stakeholder engagement, this strategy can be particularly helpful if a State has limited experience with CMEs. Options for learning from others include:

• Arranging conference calls with experienced States.
• Participating in a learning collaborative with other States.
• Observing how services are actually structured and provided by visiting another State.
• Asking staff in experienced States to help train State agency staff new to CME concepts on the wraparound model.
• Contracting with technical assistance organizations to provide advice on complex problems such as CME financing and program evaluation or to help facilitate cross-State learning.

Strategy 3: Use Data to Drive Decisions

The right information is essential for a State to understand how youth with complex behavioral health needs receive services currently, which in turn can inform many CME design decisions.

Data derived from surveys, interviews, focus groups, content analysis of program materials, and program or participant observation can shed light on the strengths and weaknesses of the State’s existing system of service delivery and potentially identify duplicative services and unmet needs. Consider:

• Discussing potential sources of this type of information during stakeholder meetings.
• Interviewing key representatives from child-serving agencies, family advocacy groups, and provider associations.
• Reviewing child-serving agency operational plans that discuss cross-agency coordination, out-of-home placements, and services for youth with complex behavioral health needs.
• Reviewing materials created by local family advocacy groups, such as the local chapter of the National Federation of Families for Children’s Mental Health.

Analysis of administrative data (for example, enrollment, utilization, and claims data) can yield insights on:

• Numbers and characteristics of youth who could benefit from more intensive care management.
• Geographic utilization patterns of current services.
• Availability and geographic distribution of behavioral health providers and community services.
• Historical and baseline costs for services.
• An appropriate payment rate for CME services.

Because CMEs coordinate services across child-serving agencies, analyzing data on service use, cost, and eligibility from multiple agencies is especially valuable. However, even States with sophisticated, robust data systems may not have access to the required information. A State can mitigate or overcome these challenges by keeping the following strategies in mind:

• Budgeting resources to obtain and analyze data.
• Developing interagency data-sharing agreements early in the design process to avoid delays in making data-driven decisions.
• Seeking short-term technical assistance from other agencies or firms that specialize in data analysis.
• Investing resources in improving and aligning existing data systems over the long term.

In addition to facilitating CME design, improving access to data across agencies will help a State monitor and refine its CME over time (see “CME Monitoring and Evaluation” in Part 4 for more information).