Long-Term Care Integration Project: Medi-Cal Redesign Update Mark R. Meiners Ph. D. National Program Director Robert Wood Johnson Foundation Medicare/Medicaid Integration Program Physical & Behavioral Health Coordinator Conference, sponsored by Healthy San Diego Behavioral Health Work Group and SD County Health and Human Services Agency January, 18, 2005, San Diego, CA

Background to MMIP Experiences Robert Wood Johnson Foundation 15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VT For Background and Technical Assistance Documents see:

Medi-Cal Redesign and the San Diego Long Term Care Integration Project

Medi-Cal Redsign Basics  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 Community Planning Process  From 50 to 400+ key stakeholders over past 4 years: 10,000 + hours  Seeking to improve system of care for consumers and providers  Planning within state LTCIP authorization (form follows funding)

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

SD LTCIP Components  BOS: “come back with 3 options” For LTCIP  Since then: Strategy development:  Network of Care  Physician Strategy  HSD Health Plan/Pilot Projects

Network of Care  Beta testing with  consumers and caregivers  community based organizations  other providers, Call Center staff  To develop “continuous quality improvement” program  Measure behavior changes of providers and consumers

Physician Strategy  Partner w/physicians vested in chronic care  Develop interest/incentive for support of “after office” services (HCBC)  Identify care management resources to support physicians/office staff to link patients and communicate across systems  Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports

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

Health Plan Readiness  Analysis of current use and cost data  Network adequacy assessment  Care Coordination and carve outs  Quality monitoring and improvement  Linkage with non- Medi-Cal Services  Access and availability of new treatments  Stakeholder input in implementation  Compliance with Americans with Disabilities Act of 1990

Why the Interest in acute and LTC Integration and Dual Eligibles? Important public financing considerations An opportunity to do better with limited resources Cost shifting in both directions Unintended consumer consequences Managed care implications Aging of the population/Chronic Care Imperative

Key Dimensions of Dual Eligible Integrated Care Program Development »Scope and flexibility of benefits - more than M&M fee-for-service »Delivery system - broad, far reaching, options, experienced »Care integration - care teams, central records, care coordination. »Program administration - enroll, disenroll, data, payment incentives »Quality management and accountability - unified, broad, CQI »Financing and payment - flexible, aligned incentives

State Environmental Diversity Major differences in Medicaid programs Wide variations in state managed care infrastructure Differences in state goals and target populations States are in various stages of program development Divergent definitions of integration/coordination

Program Development Considerations Statewide or regional pilot (large vs. limited) Mandatory or Optional Duals/Medicaid-only Aged/Disabled Both? Timing? Well, Community Frail, Nursing Home National MCOs or Local Safety-Net Providers Provider Networks – open or closed? M/M Coordination or Integration Benefits: Comprehensive/ Carve Outs Waivers, Risk Adjustment, Enrollment Strategy Budget Neutral or Cost Saving

Managed FFS Medicare Coordination Medicare Integration Issues/Features Medicaid and Medicare reimbursed FFS No waivers required Care coordinator link between programs and providers Use of incentives (fees, co-location, reporting) Issues/Features Medicaid LTC capitated Medicare HMO enroll encouraged Various Medicaid waivers/authorities Inability to capture Medicare savings Case management lacks authority over Medicare Issues/Features 222 Medicare payment waiver & Various Medicaid waivers One contract for both payers Flexibility to use savings for non-traditional services Case management has control over both programs

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

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

MSHO: What’s Working Enrollee/family relationship with care coordinator provides assistance with navigation of the medical and LTC systems across all services in all settings for all types of enrollees Risk screening and early identification for community “well” provides preventive opportunities Dis-enrollment rate is less than 3%, low complaint and appeal rate, high consumer satisfaction, enrollment growth Lower inpatient use, especially for frail members, Cost effective: 5% savings on community LTC, lower use of nursing home after the 180 days Increased access for ethnically diverse population to community services (54% of community LTC population is nonwhite, SE Asians largest group)

MSHO: What’s Working Plan and care system investment and long term commitment Have built a viable market based infrastructure for improving chronic care for duals, learning lab for new policies, spillover starting to happen Plan and Care System Collaboratives: –Quality Improvement initiatives with geriatric focus –Care Coordinator training –Specialized tools/protocols for Care Coordinators on chronic diseases –Development of standardized measures Plans and provider interest is growing, expanding to other counties and plans

CMS Evaluation: U of MN MSHO community members have fewer preventable ER visits, particularly with increased duration and are more likely to receive preventive services, therapy and home health nursing services and used less out of home care and lower levels of in home care than control groups. Nursing home members have fewer hospital admissions, days and preventable hospital admissions and were more likely to get some preventive services than control groups. Death rates were similar for MSHO and control groups, quality indicators for nursing home residents were also comparable among both groups.

MSHO/NHC Enrollees Are More Diverse Than FFS/NHC

MSHO Trends: Lower Inpatient Use

Trends: Lower Nursing Home Admissions for Frail

Measuring Outcomes of the WI 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.

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.

Member Outcomes

Self-Determination & Choice Outcomes

Self-Determination & Choice Supports

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.

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

Result: Hospital Admission

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.

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

Comparing Hospital Use, Same People Before & After Enrollment

Comparing Nursing Home Use, Same People Before & After Enrollment

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

Physician Satisfaction

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.

TEXAS STAR+PLUS l Medicaid pilot project designed to integrate delivery of acute and long-term care services through a managed care system l Requires two Medicaid waivers: u 1915 (b) - to mandate participation u 1915 (c) - to provide home and community- based services

STAR+PLUS Objectives  Integrate Acute & Long Term Care into Managed Care System  Provide the Right Amount & Type of Service to Help People Stay as Independent as Possible  Serve People in the Most Community-based Setting Consistent with their Personal Safety  Improve Access and Quality of Care  Increase Accountability for Care  Improve Outcomes of Care  Control Costs

STAR+PLUS Eligibility Criteria l Mandatory Participation: HMO u SSI-eligible (or would be except for COLA) clients age 21 and over u MAO clients who qualify for the Community Based Alternatives (CBA) waiver u Clients who are Medicaid-eligible because they are in a Social Security exclusion program

Is STAR+PLUS Mandatory? If you are in a required group l You must enroll in a STAR+PLUS Plan for Medicaid services l Medicare services may be obtained through the provider of choice

Enrollment Broker l New Medicaid Clients l Enrollment Broker Contacts Clients by: l Telephone, Mail, In-person

STAR+PLUS Enrollment 1/1/0254,895Total 25,323Dual Eligibles 29,572Medicaid Only

STAR+PLUS Services l Acute care services (Medicaid only members) l Long term care services u Personal Care Services u Adult Day Health Services u Nursing Facility Services l Behavioral Health l Care Coordination l Waiver Services - therapy, respite, adult foster care, assisted living, DME/adaptive aids, minor home modification l Value added services - adult dental, waiver services for non-waiver members

CARE COORDINATION * HMO required to contact members within 30 days of enrollment * HMO makes home visit and assesses members needs, as appropriate * HMO assigns a care coordinator (or coordination team), as appropriate

EVALUATION CRITERIA * Consumer Satisfaction * Integration of Care * Access to Care * Quality of Care * Emphasis of Community Based Care * Impact on Budget * Impact on Providers

Utilization Analysis l In 1999, Personal Assistance Services use was 32 % higher than FFS projected. l The Community Based Alternatives program increased almost 119 percent in Harris County, but only 3.4 percent statewide. l Utilization of new generation medications by people with serious mental illnesses increased both statewide and in Harris County, but the Harris County increase did not occur until the implementation of STAR+PLUS. l Inpatient hospital utilization decreased for this population.

Care Coordination l Care Coordination Key Survey Findings u 77% were aware of a care coordinator or person who helps them get services u 74% reported it was ‘somewhat easy’ to ‘easy’ to get help from a care coordinator u 58% reported being included in decision-making about their services u 81% reported ease in obtaining services such as personal attendants or home health services u 70% were satisfied with care coordination services and 84% would consider recommending their health plan to others

LTC Provider Satisfaction l Tended to be more dissatisfied than neutral or satisfied in the areas of u Accuracy of claims payments u Timeliness of claims payments u Amount of phone work u Overall satisfaction l Those with more service experience reported lower satisfaction than those with less

Challenges  Enrollment  Medicaid Population  LTC Providers Transition  Computer Systems  Dual Eligibles

Opportunities  Early Intervention  Disease Management  Care Coordination u Home visits u Integration of care  Flexibility in service delivery

Lessons Learned l Care Coordination is the key to integration of acute and LTC services l Challenges coordinating care for dual eligibles when HMOs are only responsible for LTC l Education of all providers and stakeholders is key l Increase in administrative complexity caused provider dissatisfaction l Collaboration between competing HMOs and State is an essential piece of successful model

Summary Thoughts Integrated Care is hard and worth it!/? Future of MMIP Efforts and Accomplishments: Uncertain? Promising? Competing Agendas? Topics to watch: Special Needs Plans, Drugs, Disease Management, Care Coordination, Risk Adjustment, Consumer Directed Care; Cash Benefits, HCBS Waivers, Olmstead Decision, and Private LTC Insurance.