Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
In Maryland, the Health Services Cost Review Commission, an independent state agency, plays a vital role in health reform innovation and implementation. The agency regulates the quality and costs of hospital services. “Ultimately, our goal is to ensure everyone in the state has equitable access to high-quality hospital care,” says Tequila Terry, principal deputy director of Payment Reform and Provider Alignment at the agency.
Because the HSCRC has authority over hospitals and what they charge, it can also direct hospital efforts and allocate funding toward special, high-priority needs like behavioral health. Historically, these efforts have focused solely on hospital settings, but an agreement with the Centers for Medicare and Medicaid Innovation Center in 2019 widened the agency’s scope. It’s called the Total Cost of Care Model, and the aim is lofty: transform Maryland’s entire healthcare system.
“Under the agreement,” says Terry, “Maryland has an annual savings target for Medicare’s total cost of care.” According to CMS, the model sets Maryland on the trajectory to save Medicare more than $1 billion cumulatively by the end of 2023.
The rate-setting agency continues to do global budgets with hospitals, but the 2019 agreement with CMMI broadened the focus beyond hospital walls to improve population health. “It’s these two elements together,” points out Terry, “that have allowed us to focus on behavioral health and crisis services.”
The new total cost of care model builds on Maryland’s all-payer model, which has existed since 1977, thanks to a long-standing Medicare waiver. The waiver exempts the state from inpatient and outpatient prospective payment systems, allowing the state to set its own rates for these services.
Terry says the Total Cost of Care Model is the impetus for the commission’s statewide integrated health improvement strategy, which concentrates on public and private collaborations between healthcare stakeholders to address disparities, improve health, and reduce healthcare costs in Maryland, including those related to behavioral health. “We knew that if we wanted to address overdose mortality and high utilization in hospitals,” she says, “then we had to look at the role of behavioral health.”
When facing a substance use or mental health crisis, many adults and young people in Maryland end up in the emergency department because that’s often the only place to go. “That’s not a trend we want to continue,” says Terry. “We want to get people into more appropriate settings of care.”
Terry and her colleagues began looking at what role hospitals could play alongside their community partners to reduce psychiatric readmission rates and improve overall population health. To foster innovation, the HSCRC developed the Regional Partnership Catalyst Program. The program includes $165.4 million in funding over five years, of which $79.1 million goes to fund behavioral health crisis services.
In early 2020, the agency released a request for proposals, asking hospitals to submit plans that collaborate with community partners and integrate the Crisis Now model. “The aim,” says Terry, “was to build out Maryland’s crisis services infrastructure.” “It was important to us that this was a partnership model with communities and not a hospital-only initiative.” While the agency didn’t specify the community partners that had to be included in the catalyst program, Terry and her colleagues wanted hospital applicants to pull in those pertinent to that specific area like local health departments and health authorities, social services, first responders, advocacy groups, and people with lived experience.
“Each community has different resources at play, but we wanted hospitals to engage and collaborate with partners who can influence health.”
In the fall, Terry and her colleagues approved three regional behavioral health proposals. Awardees include the Greater Baltimore Regional Integrated Crisis System, Totally Linking Care, and the Tri-County Behavioral Health Engagement.
The recipient of the most considerable portion of the program’s behavioral health crisis funding (nearly $45 million) is GBRICS. The system partnership includes 17 hospitals, community groups, and the behavioral health authorities and local governments of Baltimore City, Baltimore County, Carroll County, and Howard County. The new system will include a care traffic control call center, modeled after the Georgia Crisis and Access Line (GCAL) in Georgia, standalone walk-in clinics, and standardized 24/7 mobile crisis in every jurisdiction.
The Horizon Foundation, a health philanthropy in Howard County, Maryland, provided seed money to support the coalition and consultants who developed the GBRICS proposal for the HSCRC. Nikki Highsmith Vernick, the philanthropy’s president and CEO, and Glenn E. Schneider, the foundation’s chief program officer, told #CrisisTalk in February that at GBRICS’ core is a data-driven care traffic control center, which will triage and monitor incoming 988 calls. Telecom companies must make the three-digit number for behavioral health, substance use, and suicide crises available nationwide no later than July 16, 2022.
“The idea,” said Schneider, “is that care traffic control will triage all behavioral health crisis calls, determining next steps, if needed, such as dispatching mobile crisis or directing the person to a nearby walk-in clinic.” System partners will also collaborate with first responders and the Maryland Institute for Emergency Medical Services System to develop diversion protocols.
The second awardee, Totally Linking Care, is in Prince George’s County. The partners are using the funding (close to $23 million) to integrate call center technology to support mobile crisis services and create an advanced real-time dashboard. “They want to give mobile crisis teams in the field the ability to track and rapidly connect people with community services,” says Terry. She points out that the county already had a mobile crisis program, but the funding allows them to expand the service to better match the needs of the county’s growing population. “Only one or two teams were serving Prince George’s County, which has a population of nearly one million people.” The TLC innovation also focuses on in-hospital diversion, providing improved triage in the emergency department—so that people with behavioral health issues are placed in a non-hospital, non-jail setting.
“The hospital,” says Terry, “is now acting in the role of care coordination to a much greater degree than they would have otherwise or historically, providing a true warm handoff to community-based facilities.”
The third regional behavioral health awardee is the Tri-County Behavioral Health Engagement, also known as TRIBE, which includes Wicomico, Worcester, and Somerset counties. Terry points out that much of the area is rural with limited access to care. “It can be miles and miles before you see another home, let alone any kind of healthcare resource,” she says. There are only two hospitals on the eastern shore: TidalHealth Peninsula Regional and Atlantic General Hospital. The hospitals are collaborating with community partners to use the funding ($11.3 million) to develop two standalone behavioral health urgent care centers.
The three-county collaboration will build the first center in Salisbury, near TidalHealth Peninsula Regional. It will be open seven days a week with extended hours. The environment, notes the hospital, will be “home-like.” They will build the second location near Atlantic General Hospital in Berlin; it will start off six days a week and then expand to seven.
Transportation, points out Terry, is a chronic barrier to care in both rural and urban areas. The awardees are coming up with innovative solutions, including partnerships with services like Lyft and Uber, funded through the catalyst program, to ensure people have transportation to psychiatric urgent care centers and other community-based partners. “It underscores the thoughtful approach the hospitals and their partners have put into these initiatives,” says Terry. “They peeled back the barriers and then built solutions into their designs.”
As Maryland prepares for 988, the Regional Partnership Catalyst Program, notes Terry, is one sliver of the pie. “The partnerships are in three regions, but that doesn’t cover the entire state,” she says. However, it has sparked a more extensive discussion, led by the Maryland Department of Health, Behavioral Health Administration.
“The administration has used the catalyst program to jump-start a dialogue on our long-term vision for a state-wide, comprehensive, and integrated crisis system,” says Terry. “That’s incredibly exciting.”
