San Diego Long Term Care Integration Project (LTCIP) November 9, 2005 LTCIP Planning Committee

San Diego County Board of Supervisors & State Office of Long Term Care Jean Shepard, Director County of San Diego, Health & Human Services Agency, (HHSA) Advisory Group: Goal: Make final decisions and recommendations for inclusion in the plan. Planning Committee: Goal: Guide the LTCIP planning process. Suspended Workgroups pending need for further action/decision-making Health Plan Partners Workgroup Finance/Data Workgroup Options Workgroup Internet Facilitates communication Provides broad public education Pamela B. Smith, Project Director Evalyn Greb, Project Manager Aging & Independence Services Lead County Agency MH & SA Workgroup Explore use of the Healthy San Diego model for potential Service delivery system for LTCIP. Determine the financial feasibility of the proposed LTCIP for San Diego County. Make recommendations to Planning Committee re: inclusion of mental health and substance abuse services in LTCIP. LTCI Strategies: 1) Network of Care 2) Physician Strategy 3) Healthy San Diego Plus Ad Hoc workgroups: Care Management, Provider Network Development, Cultural Responsiveness Governance -Case Management -Info/Technology -Quality Assurance -Scope of Services -Workforce Issues -Developmental Disabilities -Community Network Development Community Education Workgroup Explore use of public health education models that promote improved chronic care management for LTCIP Long Term Care Integration Project Organizational Chart & Decision Tree April 2005

Why the Interest in ALTCI? Unintended consumer consequences Cost shifting in both directions Important public financing considerations An opportunity to do better with limited resources Managed/Integrated Care implications Aging of the population/Chronic Care Imperative

Journal of the American Geriatrics Society, Feb In-Home Services Day Health Care Acute Hospital Transit Skilled Nursing Facility Medical Specialty Meals Service Primary Care MRS. C. Ideal System Mrs. C & Care Manager

Special Needs Plans Institutional Beneficiaries (In or expected reside ther >90 days; Community NHC) Dually Eligible (subsets of duals OK) Beneficaries with Chronic Conditions (untested to be evaluated on case by case; e.g. disease specific, plan focuses) Lumpers vs. Splitters!

CMS Guidance to Integrating Medicare/Medicaid Models: -Buy-In Wraparound -Capitated Wraparound -Three-Party Integrated -Plan-Level Integrated Key Considerations: -Enrollment -Operations -Benefits -Payments -Appeals -Part D Implementation

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Community Resources and Policy Self- Manage- ment Support Delivery System Design Clinical Information Systems Develop Strategies for Each Component of the CCM Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population A P S D A P S D A P S D D S P A A P S D A P S D A P S D D S P A Organiz -ation of health care Decision Support

Core Building Blocks -Targeting Beneficiaries: Risk vs. Reward -Case Management / Care Coordination - Integrating Information - Quality Methods and Measures - Primary Care / Chronic Care Management

Bringing Medicare and MassHealth Together Senior Care Options

What Works? Centralized Enrollee Record 24/7 Access to Nurse Case Manager Joint CMS-state Medicare-style monitoring “Extra” benefits, i.e. vision, dental, hearing, podiatry services to encourage enrollments Rates sufficient for start-up phase “Real” people to support automated enrollment, screening, and reporting requirements

Exciting Outcomes High enrollment in underserved, diverse neighborhoods (SCOs hire residents to do marketing/customer service) Initial resistance by Aging industry slowly shifting to new AAA-SCO business MMA transition to SNP MA-PD option as fast track to formal Medicare status Enthusiastic, high-profile bi-partisan support within state government

Wisconsin Partnership Program Charting the Future for Special Needs Plans: 2005 Leadership Forum Fairfax, Virginia Nancy Crawford November 2005

Outcomes

Outcomes

Results of Provider Satisfaction Survey

Medi-Cal Redesign Revisited Mandatory Medi-Cal Managed Care for Aged, Blind, and Disabled (ABDs) clients in all current managed care counties Implement Acute and LTC Integration Projects in Contra Costa, Orange, and San Diego to test innovative approached for enabling more individuals to receive care in setting that maximize community integration.

San Diego Stakeholder LTCIP Vision for Elderly & Disabled Develop “system” that: –provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus –pools associated (categorical) funding –is consumer driven and responsive –expands access to/options for care –Utilizes existing providers

Stakeholder Vision (continued) –Fairly compensates all providers w/rate structure developed locally –Engages MD as pivotal team member –Decreases fragmentation/duplication w/single point of entry, single plan of care –Improves quality & is budget neutral –Implements Olmstead Decision locally –Maximizes federal and state funding

ALTCI Building Blocks Stakeholder Process Community Education and Outreach Care Coordination Improvement Community Network Development Community & Cultural Responsiveness Personal Care Workforce Support Integrated IT Development Primary Care Teams/Physician support Quality Monitoring and Measurement

Health San Diego Plus MediCal Aged, Blind, and Disabled offered voluntary enrollment in LTC Integrated Plan Models of care integrated across the health, social, and supportive services continuum: –Private entity to contract with State through RFP with stakeholder support –Healthy San Diego Health Plus Plans to develop program details with consultant resources

Community Feedback on Stakeholder Recommendations Provider Network Care Management Community & Cultural Responsiveness

Provider Network Development/ Member Service Recommendations –Add geriatric, disability, social service expertise –Define minimum access standards for health and social services, including personal care services –Define minimum standards for member services/training of providers across the continuum to meet the individual health and social service needs of aged and disabled members Consultants: Scotti Kluess, Carol Zernial

Care Management Recommendations –Finalize CM model, based on previous work and stakeholder input –Develop standards and performance measures with State, County & stakeholders for the RFSQ –Identify CM tools, such as assessment instrument and care plan format –Identify source and develop community-wide plan for comprehensive training/certification? Staff: Brenda Schmitthenner

Community & Cultural Responsiveness –Recommend plan to involve consumers/ caregivers in decision-making for self-direction, standards for new system of care –Identify issues of diversity (cultural, physical, cognitive+) in re: access, outreach, education –Develop minimum requirements and performance measures w/State, County, stakeholders – Recommend HSD+ training plan and materials to be translated into threshold languages Workgroup Facilitator: Jong Won Min, PH.D.