The legislature finds that whole-person care that includes access to behavioral health, care coordination, and social supports at the point of entry is essential for families. In 2021, over 44 percent of middle school students and 57 percent of high school students reported feeling depressed most days. One in five mothers suffer from mood disorders after birth while only 16 percent receive treatment. Meanwhile, 78 percent of primary care doctors who refer kids for behavioral health care receive no further information or coordination after the referral. Multiform strategies are needed to meet kids and families where they are to deliver needed behavioral health interventions and social supports. While current initiatives, like certified community behavioral health clinics, promise to expand access to integrated care and care coordination for families that present to behavioral health clinics, it is necessary to plan for whole-person care throughout the delivery system, including for families whose primary point of entry is through primary care.
The legislature further finds that the unique relationship between primary care providers and patients makes primary care well positioned to deploy integrated whole-person care strategies that include behavioral health and social supports. Primary care is a main driver of prevention and early detection, so investment in improved primary care services, connectivity to other parts of the delivery system, and patient engagement will improve patient outcomes and lower the total cost of care. To achieve these outcomes, the legislature intends to invest in primary care transformation accomplished through a multipayer primary care transformation model developed by the health care authority in consultation with stakeholders across the health delivery system.
The definitions in this section apply throughout this chapter unless the context clearly requires otherwise.
"Authority" means the Washington state health care authority.
"Bidirectional integration" means integrating behavioral health services into primary care settings and integrating primary care services into behavioral health settings.
"Children's health program" means the health care services program provided to children under eighteen years of age and in households with incomes at or below the federal poverty level as annually defined by the federal department of health and human services as adjusted for family size, and who are not otherwise eligible for medical assistance or the limited casualty program for the medically needy.
"Chronic care management" means the health care management within a health home of persons identified with, or at high risk for, one or more chronic conditions. Effective chronic care management:
Actively assists patients to acquire self-care skills to improve functioning and health outcomes, and slow the progression of disease or disability;
Employs evidence-based clinical practices;
Coordinates care across health care settings and providers, including tracking referrals;
Provides ready access to behavioral health services that are, to the extent possible, integrated with primary care; and
Uses appropriate community resources to support individual patients and families in managing chronic conditions.
"Chronic condition" means a prolonged condition and includes, but is not limited to:
A mental health condition;
A substance use disorder;
Heart disease; and
Being overweight, as evidenced by a body mass index over twenty-five.
"County" means the board of county commissioners, county council, county executive, or tribal jurisdiction, or its designee.
"Department" means the department of social and health services.
"Department of health" means the Washington state department of health created pursuant to RCW 43.70.020.
"Director" means the director of the Washington state health care authority.
"Full benefit dual eligible beneficiary" means an individual who, for any month: Has coverage for the month under a medicare prescription drug plan or medicare advantage plan with part D coverage; and is determined eligible by the state for full medicaid benefits for the month under any eligibility category in the state's medicaid plan or a section 1115 demonstration waiver that provides pharmacy benefits.
"Health home" or "primary care health home" means coordinated health care provided by a licensed primary care provider coordinating all medical care services, and a multidisciplinary health care team comprised of clinical and nonclinical staff. The term "coordinating all medical care services" shall not be construed to require prior authorization by a primary care provider in order for a patient to receive treatment for covered services by an optometrist licensed under chapter 18.53 RCW. Primary care health home services shall include those services defined as health home services in 42 U.S.C. Sec. 1396w-4 and, in addition, may include, but are not limited to:
Comprehensive care management including, but not limited to, chronic care treatment and management;
Extended hours of service;
Multiple ways for patients to communicate with the team, including electronically and by phone;
Education of patients on self-care, prevention, and health promotion, including the use of patient decision aids;
Coordinating and assuring smooth transitions and follow-up from inpatient to other settings;
Individual and family support including authorized representatives;
The use of information technology to link services, track tests, generate patient registries, and provide clinical data; and
Ongoing performance reporting and quality improvement.
"Internal management" means the administration of medical assistance, medical care services, the children's health program, and the limited casualty program.
"Limited casualty program" means the medical care program provided to medically needy persons as defined under Title XIX of the federal social security act, and to medically indigent persons who are without income or resources sufficient to secure necessary medical services.
"Medical assistance" means the federal aid medical care program provided to categorically needy persons as defined under Title XIX of the federal social security act.
"Medical care services" means the limited scope of care financed by state funds and provided to persons who are not eligible for medicaid under RCW 74.09.510 and who are eligible for the aged, blind, or disabled assistance program authorized in RCW 74.62.030 or the essential needs and housing support program pursuant to RCW 74.04.805.
"Multidisciplinary health care team" means an interdisciplinary team of health professionals which may include, but is not limited to, medical specialists, nurses, pharmacists, nutritionists, dieticians, social workers, behavioral and mental health providers including substance use disorder prevention and treatment providers, doctors of chiropractic, physical therapists, licensed complementary and alternative medicine practitioners, home care and other long-term care providers, and physicians' assistants.
"Nursing home" means nursing home as defined in RCW 18.51.010.
"Poverty" means the federal poverty level determined annually by the United States department of health and human services, or successor agency.
"Primary care behavioral health" means a health care integration model in which behavioral health care is colocated, collaborative, and integrated within a primary care setting.
"Primary care provider" means a general practice physician, family practitioner, internist, pediatrician, osteopathic physician, naturopath, physician assistant, and advanced registered nurse practitioner licensed under Title 18 RCW.
"Secretary" means the secretary of social and health services.
"Whole-person care in behavioral health" means a health care integration model in which primary care services are integrated into a behavioral health setting either through colocation or community-based care management.
"Health navigator" means a member of a health care team who helps individuals overcome barriers and facilitate access to services by increasing health knowledge and self-sufficiency through a range of evidence-based activities such as outreach, community education, informal counseling, social support, and advocacy which impact social determinants of health. Health navigators are nonlicensed and are typically trusted members of the community with an unusually close understanding of the community served.
By January 1, 2023, managed care organizations shall make reimbursement for care coordination services performed by nonlicensed staff acting in the role of a health navigator available to primary care clinics that have not fully transitioned to the multipayer primary care transformation model developed pursuant to section 4 of this act, using funding provided for medicaid administrative services.
The authority shall work with stakeholders to complete development of its multipayer primary care transformation model to improve access to and quality of services covered by medicaid, public employees' benefits board, and school employees' benefits board programs and begin phasing in value-based payment and accountability for top tier readiness certification clinics by January 1, 2023.
The multipayer primary care transformation model shall, if practicable, be designed to achieve cost neutrality when fully phased in for each participating clinic.
The multipayer primary care transformation model shall include, but not be limited to, the following components:
Coordination of payer functions and resources, such as centralizing evaluation of performance and standing;
Reduction of burden on practices by reducing the need to comply with multiple contracting and compliance standards for different payers;
Receipt of a consolidated service payment that removes the incentive to bill for a higher volume of services;
Standardization of accountabilities for standards of care and practice capability expectations, which shall include, but not be limited to:
Use of appropriate behavioral health screening tools annually with documented follow-up protocols; and
Access to team-based care strategies including patient support through health navigator services;
A transformation fee to support practices while they are building capacity to satisfy provider accountabilities; and
Increased payment for quality based on performance across several quality measures, including behavioral health.
The authority shall report to the governor and appropriate committees of the legislature by December 1, 2023, describing the final multipayer primary care transformation model, progress with implementation, and a strategy and timeline to complete implementation in primary care clinics across the state.
The department of health shall contract with an organization that represents pediatric primary care needs in Washington state to convene community-based organizations dedicated to children's mental health in order to establish and implement an equity-focused curriculum by January 1, 2023, with the goal to prepare health navigators in the unique needs of children, adolescents, and their families.