Building Scalable Independent Assessments to Improve Arkansas Medicaid Outcomes

Assessing who needs what services

The Arkansas Department of Human Services (DHS) has long pursued a clear goal: Improve outcomes for Medicaid beneficiaries while ensuring responsible stewardship of public resources. It successfully enacted a plan to save $835 million in Medicaid costs between 2017 and 2021, mainly through program efficiencies, improved utilization of services and better outcomes.

Making this a reality called for a coordinated effort to manage the care of beneficiaries with complex medical and behavioral health conditions.

Arkansas now spends about $2 billion each year on a range of Medicaid services for 300,000 people. These individuals have at least one claim for one of the following:

• Behavioral health
• Substance use disorder
• Developmental/intellectual disability (DD/ID) services

Within this group, the state is focusing aggressively on about 40,000 individuals with higher levels of need. They account for roughly $1 billion in Medicaid spending.

Jennifer Petersen is the program director for Optum® State Government Solutions and oversees the Arkansas Independent Assessment Program. “Optum performed most of its functional assessments on this group of people. This helped determine who needs what services — which ones, how many and how often.”

A single tool across agencies

A core strength of the Arkansas Independent Assessment Program is its use of a single, functional assessment approach across multiple DHS divisions. Assessment responses are scored to generate an initial tier determination, which the state uses to authorize appropriate levels of service based on individual need.

Over more than six years, the program has supported more than 500,000 assessments statewide, with approximately 66,000 assessments conducted annually across the following DHS divisions:

• Division of Aging and Adult Services (DAAS)
• Division of Behavioral Health Services (DBHS)
• Developmental Disability Services (DDS)

“Using a single tool enables more coordinated care for individuals with more than one issue,” says Petersen. “For example, a person may have both mental health issues and developmental disabilities.”

“Our assessments are ‘functional’ rather than ‘clinical,’” says Petersen. This means they focus on how individuals function in their daily lives and cover a range of categories, including:

• Activities of daily living (ADLs) such as eating, bathing, dressing and personal hygiene
• Ability to prepare meals and manage medications and finances
• Memory and cognition
• Ability to communicate
• Ability to provide for their own safety and well-being
• Issues related to depression, suicide, alcoholism, substance use and gambling

A unique partnership model

“Provider involvement is critical to achieving the state’s goal of improving outcomes and reducing costs,” says Petersen. To coordinate care among this group, Arkansas DHS has established a unique model. Providers of specialty and medical services are entering into new partnerships with experienced organizations that perform the administrative functions of managed care.

Together, these groups of providers and their managed care partners are developing new business organizations called Provider-Led Arkansas Shared Savings Entity (PASSE). Each PASSE is responsible for integrating:

• Physical health services
• Behavioral health services
• Specialized home- and community-based services (HCBS) for individuals who need intensive levels of treatment or care

“The assessments offer them a more complete view of their patients,” says Petersen. “The state makes the ultimate decision on the type and level of care a beneficiary will receive. And Optum is not involved in any care plan development decisions. Those determinations are made by providers, the beneficiary’s care coordinator — who works for the PASSE — or the nurse who cares for the aged, all of whom receive the results of assessments.”

 What Optum provides includes:

• A comprehensive assessment tool
• Qualified professionals to objectively and reliably administer the tool
• The underlying technology platform required to support the tool and collect and report data across population groups and programs
• Provider training, support and outreach

Getting up to speed

Collaboration with the state and providers has been the key to success in conducting so many assessments every year. Like any broad-based program, there were some glitches at the beginning. One of the key steps was to embed assessors at provider sites so they could conduct assessments as part of a patient’s regular visit for an exam, a consultation or to get a prescription. They could also conduct assessments at care facilities and institutions. 

This “embed” approach helped in many ways. It located assessors “where the beneficiaries were.” It mitigated — and virtually eliminated — the negative “telemarketer effect” that assessors would experience when they called beneficiaries at home. It also engaged providers in the process in a more active way.

 In the first year, the number of assessments conducted leapt exponentially. In 3 months, they went from a low of around 30 per day to more than 500 per day — and sometimes as many as 700 daily. “More than 160 assessors were embedded at provider locations across the state,” says Petersen, ‘touching’ 250 individual provider locations.

Meeting people where they are

DHS was pleased with the approach and the results. Governor Asa Hutchinson was too. He expressed his confidence in Optum to DHS and to an Optum assessor whom he ran into as she was having lunch in a small town. He complimented her on the company’s performance.

“We’ve also had positive response from providers, social workers and beneficiaries and their families,” says Petersen. “They see the assessment approach paying dividends. They have confidence that the assessments will be conducted in a quality way."

During the COVID-19 pandemic, Optum and the state of Arkansas collaborated to transition to telephone or video reassessments. This was made easier by changes in state legislation and national CMS rules. For in-person assessments, they adhered to CDC guidelines, including social distancing and masking. And they implemented a prescreening process to check for COVID-19 symptoms or exposure before deciding on face-to-face meetings. This approach ensured safety and prevented COVID-19 cases during assessment meetings.

“We plan to continue offering telephone and video reassessments for behavioral health and developmental disabilities beneficiaries,” says Petersen. “We also plan to add texting for appointment confirmations and rescheduling, aligning with industry best practice.”

The program has expanded and improved the assessment process. It’s expanded by conducting thousands of additional assessments, including:

• Behavioral health renewals
• Assessments for the PHE unwinding
• Specialized assessments for high-risk groups and aging clients

They are also refining the assessment process based on feedback from assessors and their interactions with health care providers and facilities. This ensures the program adapts to better meet beneficiary needs.