SECTION 1: Chapter 6D of the General Laws is hereby amended by inserting after section 15 the following new section:
Section 15A. Patient Centered Access to Behavioral Health Services in Accountable Care Organizations
Section1. Definitions. As used in this chapter, the following words shall, unless the context clearly requires otherwise, have the following meanings:--
“Behavioral health specialist” shall mean a licensed physician who specializes in the practice of psychiatry, a licensed psychologist, a licensed independent clinical social worker, a licensed mental health counselor, a licensed nurse mental health clinical specialist or a licensed marriage and family therapist within the lawful scope of practice for such therapist.
“Patient Engagement Advocate” shall mean a human services professional who provides patient navigation and care coordination services throughout the continuum of care. Advocates must have a minimum of an associates degree and/or demonstrated lived experience as a self-advocate or as a patient advocate for a family member dealing with mental health and/or substance use issues."
“Continuum of care” shall mean a system that guides and tracks patients over time through a comprehensive array of health services spanning all levels and intensity of care throughout the treatment process and into post-recovery follow-up to prevent relapse.
“Patient navigation and care coordination services” shall mean services offered by an ACO through Patient Engagement Advocates with the goal of removing barriers that prevent patients from seeking care, helping a patient follow through with a recommended course of treatment, and maintaining their gains after treatment:
Section 2. (a) All Accountable Care Organizations (ACOs) in the Commonwealth certified by the Health Policy Commission shall offer patient navigation and care coordination services as defined below for patients with a diagnosed mental illness or substance use disorder and for patients with symptoms that suggest a possible mental illness or substance use disorder as determined by a licensed health care provider. These services shall constitute a requirement for the certification of new ACOs by the Health Policy Commission and shall constitute a new requirement for existing ACOs six months following the effective date of this act. The services are to be offered by Patient Engagement Advocates with the consent of the patient. One Patient Engagement Advocate may be assigned to multiple patients, but each patient must be assigned to a primary Patient Engagement Advocate. In ACOs where multiple navigators are managing different components of a patient’s care, the Patient Engagement Advocate will serve as the lead navigator that coordinates care among the other navigators. The services provided as part of the Patient Engagement Advocate Program shall include, but not be limited to the following:
i. Performing an initial intake to assess the patient’s needs. If the patient does not have a diagnosis, the Advocate shall refer the patient to a clinician who can determine their condition and recommend a plan of action/course of treatment. This may involve referral to additional specialists. Once a diagnosis has been obtained, the Advocate, with the patient’s consent, shall help the patient follow through with the plan of action set forth by the diagnosing clinician;
ii. Finding an appropriate provider to treat the condition(s) if outside the expertise of the clinician who provided the initial diagnosis, including contacting and screening providers on the patient’s behalf;
iii. Assisting with navigating health insurance; including but not limited to, helping the patient understand cost-sharing, finding in-network providers, assisting with referrals, assisting with appeals, explaining benefits and helping the patient find new insurance during open enrollment periods or due to a qualifying life event if their current insurance plan does not meet their needs.
iv. Finding alternative sources of support if a patient is put on a waiting list, including, but not limited to, coordinating with the patient’s primary care provider, exploring complementary therapies that could offer relief, online counseling and peer-to-peer support;
v. Scheduling initial appointments for patients and reminding them to go to their appointments.
vi. Providing or coordinating transportation to appointments if this is a potential barrier to care;
vii. Providing support with medication adherence to ensure patients take the medications prescribed by their clinician.
viii. Provider-matching follow-up to see if the current provider is a good match and if not, finding a different provider. Patient Engagement Advocates will continue to check up on patients as they receive treatment as an additional source of support;
ix. Coordinating care between the patient’s PCP and different specialists treating the same patient to ensure they are communicating with each other;
x. Post-treatment follow-up to ensure that patients are maintaining their gains and do not relapse; and
xi. Additional duties may be designated by the commission in consultation with ACOs, health plans and patient advocates.
(b) All PCPs within an ACO shall refer patients with a diagnosed mental illness or substance use disorder, or with symptoms suggesting a possible mental illness or substance use disorder to the Patient Engagement Advocates. With the patient’s consent, such Advocate shall work with the patient to identify an appropriate behavioral health specialist for the patient’s needs and shall work with the patient to eliminate all barriers to accessing such specialist. The Patient Engagement Advocates shall follow up to ensure the patient gets an appointment.
(c) ACOs shall not restrict referrals to only behavioral health specialists who are part of the ACO.
(d) Non-behavioral health specialists within the same ACO whose patients also present with symptoms of mental illness or substance use disorder shall inform the patient’s PCP of a possible behavioral health issue within 7 days of identifying non-emergency symptoms. With the patient’s consent, the PCP shall then refer the patient to a Patient Engagement Advocate, as described in paragraph (a). For all emergency symptoms, the patient shall be referred to the nearest emergency room.
Section 3. The Secretary of Health and Human Services shall provide funding for at least one pilot program with a community-based organization that offers the services described above, and in addition, offers the following:
(a) Patient, caregiver and survivor services, including the Patient Engagement Advocates defined in Section 1; e-support networks; financial counseling; referrals to online Cognitive Behavioral Therapy (CBT) and for complementary, integrative therapies; and an evidence-based patient empowerment program, designed to give patients the tools to improve their self-concept, develop the confidence to seek treatment, and maintain their gains following treatment; and
(b) Patient empowerment, information and communication initiatives through a blog, public service announcements, patient stories, utilization of social media, videos and educational campaigns; and
(c) Provider education on the effects of stigma on patient engagement in treatment; on best practices for reducing stigma in clinical settings; strategies for integrating behavioral health into primary care; and strategies to maximize patient engagement in their own treatment.
Section 4. The Health Policy Commission shall promulgate regulations to implement the provisions of Sections 1 and 2 within 3 months of the effective date of this law.
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