Community Based Organizations are from Venus; Health Care Organizations are from Mars MOW Annual Conference August 2015 Sharon R Williams, CEO Williams.

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Presentation transcript:

Community Based Organizations are from Venus; Health Care Organizations are from Mars MOW Annual Conference August 2015 Sharon R Williams, CEO Williams Jaxon Consulting, LLC

When Worlds Collide  Policy Catalysts  Older Americans Act, 1965  Social Security Act: Titles III, VII, XVIII and XIX  Americans w/ Disabilities Act, 1973  Rehabilitation Act, 1973  Balanced Budget Act, 1997  Medicare Prescription Drug Improvementand Modernization Act (MMA), 2003  Affordable Care Act, 2010  Medicaid MLTSS rules, 2015  Olmstead Decision

They’ve Been Living Among Us for a While  Medicaid & Medicare managed care reforms have been revolutionizing health care delivery and changing the dynamics of other related industries/systems…  Public Health Institutions  Hospitals  Nursing Homes  Physicians Now it’s our turn!!!

Why We Must Join Forces With the Klingons  Integrated Care Movement  Triple AIM (ACA)  Improving the experience of care for consumers  Improving the health of populations  Reducing per capita costs of health care  Administrative/Programmatic Simplification  Person Centered Planning

WHO are Your Fellow Space Travelers?  Hospitals  Accountable Care Organizations (ACO)  Insurers/Managed Care Organizations (MCO)  Medicaid Managed Care  Dual Demonstration Contractors  Medicare Advantage  Market Place  Commercial Health Plans  Physician Groups/Federally Qualified Health Centers/Rural Health Centers  Medicaid/Medicare fee-for-service  Others—unions/employers

There IS Common Ground  Quality  Care coordination  Improved consumer outcomes/satisfaction  De-emphasis on institutional care  Cost containment  Utilization of a network delivery system for covered  Federal/State oversight

What Key Objectives are Important to the Aliens?  Improving health outcomes/quality  Improved coordination of care  Decrease gaps in care: behavioral, HCBS & medical  Improve Member Compliance: medication adherence, use of preventive services & PCP engagement  Reduce avoidable readmissions & emergency room visits  Cost containment/financial metrics  Achieving performance metrics  Member satisfaction/retention

Concepts that May be Alien to Traditional Health Care Organizations  Services that aren't ‘clinical-ized’  Person-centered care planning  In home/community engagement with consumers  Impact of Home and Community Based Services on quality/cost of care

Preparing for Launch  CBOs must develop an intimate understanding of the new CUSTOMERS’ needs, drivers and motivation and provide necessary support/services  Know how your products/services address health organizations' needs:  Do they support contractual/regulatory standards?  Do they address quality of care/health outcomes Health Employer Data information Set (HEDIS) Medicare Advantage Model of Care (MOC) or STAR Ratings  Do they impact Pay for Performance (P4P) measures?  Do they impact utilization goals?  Do they impact consumer compliance/satisfaction/retention?  What are the financial benefits?

Value Proposition  HCBS agencies have keen sense of consumers’ community based needs  Direct/personal contact with consumers/boots on the ground  Compliance with the proposed Medicaid MLTSS rules  Preventive engagement, routine monitoring  Trusted and knowledgeable community resource  Cost effective and essential services  Network adequacy/competency

Knowledge IS Power!  MOWA/state association resources  CMS Medicaid/Medicare websites  State health care associations—HMO, hospital, providers, etc.  State Medicaid Agency staff/websites  Health care industry local/national training  Alignment with other stakeholders, CILS, AAAs, Assisted Living, Nursing Homes, etc.  Kaiser Foundation, SCAN websites, etc.

References  HEDIS (  CAHPS (  Medicare STAR Ratings ( Education/Training/CMSNationalTrainingProgram/Downloads/ Star-Enrollment-Period- Job-Aid.pdf) Education/Training/CMSNationalTrainingProgram/Downloads/ Star-Enrollment-Period- Job-Aid.pdf  The Commonwealth Fund, Assessing Care Integration for Dual-Eligible Beneficiaries: A Review of Quality Measures Chosen by States in the Financial Alignment Initiative ( 724_Zainulbhai_care_integration_dual_eligibles_ib.pdf) 724_Zainulbhai_care_integration_dual_eligibles_ib.pdf  Medicare Shared Savings Program (ACO) Quality Measures and Performance Standards ( Payment/sharedsavingsprogram/Quality_Measures_Standards.html) Payment/sharedsavingsprogram/Quality_Measures_Standards.html  Disability Rights Education & Defense Fund with National Senior Citizens Law Center, “A Guide for Advocates: Identifying and Selecting LTSS Outcome Measures” (January 2013)  Health Outcomes Survey (HOS) (

May The Force Be With You!!! Thank You