1 Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004

2 Wisconsin Has Implemented Health/ Long-Term Care Programs That: n Provide Comprehensive Health & Long-term Care to People Who Meet Nursing Home Admission Criteria & are Medicaid Eligible; n Allow Consumers to Retain Choice of Primary Care Physician; n Maximize the Ability of Consumers to Live in Their Own Home & Participate in Community Life.

3 Wisconsin Has Implemented Health/ Long-Term Care Programs That: n Improve Functional & Clinical Outcomes; n Engage Members in the Decision Making Process About Their Own Care; n Minimize Reliance on Institutional Care; n Reduce Costs by Lowering the Need for Acute Care Intervention by Providing Consistent Primary Care.

4 The People Served Are:  Medicaid Eligible or Dual Eligible for Medicare and Medicaid  Diagnosed With an Average of 12.7 Different Conditions  Taking 13.7 Different Medicationson Average  In Need of Skilled Nursing Intervention

5 Wisconsin Has Implemented Two Programs Fully Integrate Medicare and Medicaid Services  Program of All-Inclusive Care for the Elderly (PACE)  The Wisconsin Partnership Program

6 Key Distinctions Between Partnership & PACE  PACE Members:  Attend a Day Center & Receive Most Services There;  Receive Care by the On-site PACE Physician;  Are Elderly.  Must Be Residents of a Large Urban Areas Capable of Supporting a PACE Site.

7 Key Distinctions Between Partnership & PACE  Partnership Members:  Select a Primary Care Physician From a Contracted Provider Network;  Receive Most Services in Their Home;  Can Be Frail Elderly or Have a Physical Disability;  The Partnership Nurse Practitioner Serves As Team’s Primary Care Representative & Accompanies the Member to Most MD Appointments;  Partnership Works in Both an Urban & Rural Setting.

8 Funding for Partnership & PACE  Both Medicare and Medicaid Benefits are Capitated and Paid to the Contractor  The Medicare Capititation is the Rate Book Multiplied by a 2.39 Risk Adjuster. (90%in 2004)  Risk Adjusted Rate Based on CMS-HCC and Frailty Adjuster (10%in 2004)  The Same Rate Setting Methodology is Used for Both PACE and Partnership

9 Funding for Partnership & PACE  Medicaid Capitation is Calculated by Discounting a Blended Average Cost for Nursing Home Care and Home and Community Bases Waiver Programs Costs.  Rates are Risk Adjusted for Age, Medicaid Only or Dual Eligible Status, and Level of Care.  The Rates for Elderly and People with Physical Disabilities Differ Significantly.  The PACE and Partnership Rates Differ Slightly Based on Case Mix

10 PMPM Comparison--Average WPP & January 1999 Waiver Population

11 How Partnership Works  Wisconsin Contracts with 4 Community Based Organizations to Provide Partnership Managed Care. Elder Care of Wisconsin Community Living Alliance Community Care Organization Community Health Partnership

12 How Partnership Works 

13 How Partnership Works  Partnership Organizations are at Full Risk for All Health and Long-Term Care Outcomes.  Both Medicare and Medicaid Capitation Payments are Made to the Organizations.  The Partnership Organizations Subcontract with Various Providers including Primary Care Physicians and Hospitals and Pay Them on a Fee-For-Service Basis

14 How Partnership Works  Care is Coordinated Through an Interdisciplinary Team which includes: The Member Primary Care Physician (PCP) Nurse Practitioner (NP) Registered Nurse (RN) Social Worker

15 How Partnership Works  The NP Meets with the PCP to Establish a Collaborative Practice Agreement that Often Leads to the Delegation of Primary Care to the NP.  The NP Acts as the Liaison Between the PCP, the Member and the Remainder of the Team.  RNs Provide Both Care Management and Skilled Nursing Care.  Social Workers Provide both Psychosocial and other Supportive Services as Necessary

16 How Partnership Works  Provides Prevention Services to Minimize the Need for Inpatient and Emergency Room Care.  Provides Community Based, Supportive Services to Minimize the Need for Nursing Home Care.  Accompanies the Member to Physician Visits and “Translates” Physician Recommendation for the Benefit of the Member and the Team.

17 How Partnership Works  Assures that Member Concerns and Preferences are Understood.  Assures Follow Through with Physician Recommendations.  Promotes Quality of Life by Supporting Member Specified Outcome.

18 Measuring Outcomes of the Partnership Program  The Department of Health and Family Services is using several methods, both traditional and innovative, to measure quality & effectiveness:  14 Member Outcomes Based on Member’s Input about his/her Quality of Life;  Incidence of ACSCs (ambulatory care sensitive conditions);  Utilization of Inpatient Hospital & Nursing Home Care Before & After Partnership.

19 14 Member Outcomes  Developed by the Council on Quality and Leadership, a national accreditation agency for community disability programs.  Determines whether: members’ desired outcomes are being met, and the support the member needs to achieve the outcome has been put in place by the team.

20 Member Outcomes

21 Self-Determination & Choice Outcomes

22 Self-Determination & Choice Supports

23 Health Care Outcomes Staff Compile & Trend Data On Hospitalizations For Ambulatory Care Sensitive Conditions (ACSC): ACSCs are defined by the Institute of Medicine as conditions for which good access to primary care should reduce the need for hospital admissions. n

24 Result: Hospital Admission The Rate of Hospital Admissions for Ambulatory Care Sensitive Conditions Decreased by 41.1 % from 2000 to 2002.

25 Result: Hospital Admission

26 Result: Hospital Admission

27 Result: Access to Dental Care Access to Medicaid funded dental care remains difficult in Wisconsin. For example: 17% of home and community-based waiver programs’ for elderly and people with physical disabilities had dental visits in % of all participants in PACE and Wisconsin Partnership program had dental visits in 2001.

28 Result: Health Care Utilization u Using the Hospital Discharge Data Base, Staff are Able to Demonstrate Pre/Post Enrollment Hospital Utilization u Findings Show a Positive Reduction of Inpatient Hospitalization & Nursing Home Use

29 Comparing Hospital Use, Same People Before & After Enrollment

30 Comparing Nursing Home Use, Same People Before & After Enrollment

31

32 Physician Satisfaction  Survey Completed in April  40 % of Surveys Returned  Statistically Significant  95% Confidence Level

33 Physician Satisfaction

34 Physician Satisfaction

35 Physician Satisfaction

36 Areas Needing Improvement  Member, Quality of Life, Outcomes.  Further Impact on the Incidence of Hospitalizations for ACSC.  Comprehensive Evaluation.  Demonstration of Cost Effectiveness.  Provider Satisfaction.  Interventions in Cases Where there is Mental Heath and/or Chemical Dependency Concerns.

37 Areas in Need of Improvement

38 Areas in Need of Improvement

39 Areas in Need of Improvement

40 Conclusion  Partnership offers a viable alternative to PACE that can be applied to people with physical disabilities and people who live in a rural setting.  Partnership effectively delivers member- specified outcomes.  Partnership is demonstrating positive health care outcomes.