Background
Many children enrolled in Medicaid and the CHIP have complex health needs--including behavioral health needs; however, very few receive the necessary support, and often the emergency department serves as their primary source of care.
InCK was developed to integrate and coordinate care across settings to address the physical, behavioral, and social needs of these vulnerable children, particularly those with behavioral health needs or at risk of out-of-home placements, like foster care or institutions. The model positions participating in state Medicaid agencies to develop partnerships between health care providers (including behavioral health systems), schools, community-based organizations and other local service providers to support families and promote children’s health and well-being through family-centered, whole-child approaches of care.
Aims
The InCK Model aims to:
- Ensure children enrolled in Medicaid and CHIP who have complex needs get the right care, at the right time, in the right setting to support their health and reduce unnecessary hospital stays and out-of-home placements
- Eliminate care fragmentation by bringing together state Medicaid agencies, health care providers (including behavioral health systems), schools and community organizations and other local service providers to deliver coordinated, integrated care
- Strengthening community resources and empower families to play an active role in their child’s care
Innovation
The InCK Model puts children and their families at the center of their care, empowering shared decision-making between patients and providers through more resources, holistic support to address health and social needs, and personalized, achievable care plans.
Design
The key participants of the InCK Model are:
- State Medicaid Agencies; support local implementation by providing data for the geographic service area, supporting the development of information sharing arrangements and infrastructure, working to align support for the model across child-focused state agencies, and developing the pediatric alternative payment model. State Medicaid agencies participate in the model regardless of whether they also serve as the Lead Organization.
- Lead Organizations; convene community partners to integrate coordination and management of the InCK Model’s core child services for the attributed population. The Lead Organization develops service integration protocols and processes. HIPAA-covered [local] entities, including state Medicaid agencies, serve as Lead Organizations.
- Partnership Councils; include representation from all core child services, community stakeholders and payers for the attributed population. These Partnership Councils, convened by the Lead Organization, are primarily responsible for devising strategies and processes to achieve the coordination of service types for the model.
Out of Home Placement Measure
The InCK Out of Home Placement (OOHP) measure was developed to monitor and evaluate the CMS Innovation Center’s InCK Model. OOHP is the rate of new out of home placement episodes per 1,000 attributed beneficiaries within a set geographic area per year including those in long-term care facilities (such as residential care centers, nursing facilities, and intermediate care facilities); inpatient hospitalizations for behavioral health (regardless of type of hospital facility—psychiatric hospital, children’s hospital, or other hospital); and custody episodes in foster care.
More information about the InCK OOHP measure and supplemental documentation:
