San Diego Long Term Care Integration Project San Diego Psychiatric Society Presentation December 9, 2003

Community Planning Process n From 50 to 450+ key stakeholders over past 4 years: 10,000 + hours n Seeking to improve system of care for consumers and providers (SDCMS on mailing list and Advisory Group) n Agreement to use existing providers, assure fair compensation n Planning within state LTCIP authorization (form follows funding)

San Diego County Board of Supervisors & State Office of Long Term Care Rodger G. Lum, Ph.D, 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. Governance Workgroup Case Management Workgroup Finance/Data Workgroup Information Technology Workgroup Internet -Facilitates communication -Provides broad public education Pamela B. Smith, Project Director Aging & Independence Services Lead County Agency Quality Assurance Workgroup Develop a model that supports integration across the continuum of care to ensure easy access to care & services. Determine the financial feasibility of the proposed LTCIP for San Diego County. Determine consumer protection & quality assurance standards & requirement for the LTCIP. Identify the information & technology requirements needed to support a LTCI delivery system. Develop a recommendation for the governance structure for the implementation phase of the LTCIP. Workforce Issues Workgroup Increase the number of trained providers across the long term care continuum workforce, with an emphasis on quality care. Long Term Care Integration Project Organizational Chart & Decision Tree

San Diego Stakeholder LTCIP Vision for Elderly & Disabled n 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

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

Managed Care vs Integrated Care n Managed Care: –Insurance companies manage cost of cases, may interfere w/MD treatment plan –Prevention activities on population basis only –Often restricts choice and options –Many consumers unable to be adequate self-advocates

“Integrated Care” n Population & individual prevention programs n Chronic care management by “team” at home for those identified at high risk n Service delivery at lowest level of acuity n Across Medicare & Medi-Cal n Across health & social services n Flexibility for consumer due to pooled funding n Maximize public resources to develop new system for all (us!)

Why? Mrs. C: n 84 yo woman lives alone n CVA, HTN, depression, ADL and IADL dependencies n 16 medications by 6 MDs, including psychiatrist n Medicare and Medi-Cal beneficiary n Only child lives in Chicago

Legislative Authority n AB 1040 in 1995 (revised in 1998) n State Office of LTC: –provides planning $$ –provides “Center” resources –provides liaison with other state programs –approves local activity toward LTCI –will assist in procuring federal waivers

Statement of Need n Aging Population –San Diego County to increase significantly Elderly:14% today; 25-33% by 2030 From 1990 and 2010, 75+ increases by 81% 85+/minority elderly:fastest growing segments –60% of those 65+ will require long term care services at some point –Those who need service can’t find it –Care is fragmented by regulation! –Providers asked to do more w/less

Statement of Need (cont’d) n Expenditures –LTC recipients represent: 25% of Medicaid population, 67% of Medicaid expenditures San Diego ABD enrollees/month - 95,000 62% dually eligible (Medi-Medi) 90% of those 65+ are dually eligible Annual expenditures –Medi-Cal: $520,114,276 (CY 2000) –Medicare: $377,828,473 (CY 2000) –Only 7% of US population currently has private LTC insurance (narrow population can benefit) –Resources insufficient to meet future demand

From Vision to Service Delivery Model… n Explore Healthy San Diego due to: –Access, education, prevention –Advocacy –Cost-effectiveness –Population-based –Existing infrastructure –Stakeholder-designed, BUT

HSD Currently Does NOT… n Tailor the program for chronic care or aged and disabled persons n Provide “wraparound” services n Provide chronic care management on a population basis n Receive adequate reimbursement for chronic care n Have much info on “duals”

Where are we now? n Last year, BOS: “come back with 3 options” next Spring (MDs & AARP) n Since then: Dr. Mark Meiners and 3 strategies development n Expert consultant team proposal n MassHealth SCO exploration n Administrative Action Plan underway

What about Mental Health & Substance Abuse? n Current Medi-Cal carve-out (UBH) n Limited Medicare reimbursement n LTCIP stakeholders want no carve-outs n Quality of life and financial impact of untreated mental illness is huge n Inadequate resources for MHSA (1915c waiver?) n Most integration projects do not enroll disabled w/primary MH diagnosis

What about MH & SA (cont.) n Aged/disabled persons do not use MH Centers n Elderly do not self-identify as having MHSA needs n MassSCO plan: postpone primary MHSA inclusion until successfully implementing plan for elderly n Waiver could designate psychiatrist as PCP

LTCIP Mental Health Workgroup n Goal: recommendation to Planning Committee on inclusion of MH services n Chair: Dr. Margaret McCahill n Membership extended to all n Next Mtg: Jan. 7, 2004, 4 to 5:30 PM to review progress of working committee n Place: Pt. Loma Nazarene University, Mission Valley

Why should mental health stakeholders get involved? n To influence planning and decisions n To impact delivery of acute & LTC needs of individuals (support+services) n To ensure plan integrates primary, acute, social, and support services

How can you influence planning? n Get on LTCIP mailing list for updates n Participate in Planning Committee and Workgroup meetings n Log onto website for background & info: n Call or on-going input/ideas: