Long Term Care Integration Project Physician Strategy Reception: Moving Forward May 9, 2006

Medicare/Medicaid Integration Program Experiences Medicare/Medicaid Integration Program 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: Chpre.gmu.edu (Medicare/Medicaid Integration Program)

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

Background  LTC Integrated care “vision”  Healthy San Diego as service delivery model  County Medical Society  Board of Supervisors  California Endowment  Issue identification  Draft proposal for next steps

Physician Strategy  Fee-for-service initiative to improve chronic care management  Partner w/physicians vested in chronic care  Identify interest / incentives for support of home and community based services (HCBS)  On-going meetings with physicians  Develop Implementation plan  Continuous Quality Improvement

Issues for MDs: broad overview  Desire to meet elderly and disabled person’s needs but frustrated  Need help with overlay of today’s environment on a per patient basis  Need for others to: – coordinate transportation to appointments – insure patient can/does follow treatment plan – arrange for/provide needed community services (meals, in-home care, coordination)

Issues (continued)  No reimbursement for geriatric/disability assessment across domains  Little reimbursement for MD “extender” staff  No reimbursement for mobile doc mileage/time  Little assistance with translation/diversity needs (what there is may be misdirected)  Little time or reimbursement for chronic care management support

Issues (continued)  Problems in patient transitions (e.g. hospital to home)  Inappropriate use of ERs by elderly  No coordination of Medicare and Medi-Cal benefits and services  No measure of long-term outcomes only immediate costs, which is short-sighted  Too many requirements to be able to do everything the doc is supposed to do

Practice Could Be Improved By…  Single source for connecting the complex patient to all needed/appropriate services, w/feedback  “Consortium” of providers excelling in care for homebound elderly/disabled  More affordable, available in-home care (nursing, social work, therapies, safety)  Better/new IT supports  Reimbursement based on time spent supporting individual needs of patient  Better trained office staff with more resources

Key Medicare/Medicaid Integration Program Building Block: Primary Care Teamwork  Focus on holistic approach encompassing health and welfare (e.g., psychosocial, economic, environmental, social supports)  Monitor ongoing health status for early detection of problems  Emphasize health education and prevention  Support chronic care self management  Increase opportunities for communication

Draft Elements of Implementation Proposal  Resources to build a local social network of chronic care innovators across sectors, setting, and funding by: –Community development of “team dynamic” through joint provider education –Enhancement of available IT communication supports for docs, office staff, ancillary and community providers, consumers, caregivers

Proposal (continued) –Enhancement of IT links to information and referral sources and state-of-the-art decision support tools, patient education info, etc. –Work with the UCSD Geriatric Education Center to:  influence geriatric training  improve coordination between disciplines  Promote national policy improvements –Listen to doctors and other providers to develop additional policy improvements within LTCIP

Draft Implementation Plan Feedback: the Good  Engages, educates, builds trust among providers across sectors w/common goals  Good approach, proven (UCLA & Alz’s)  Recognizes needs/burdens of MDs  Builds some needed bridges

…the “Bad”  When do docs have time for this?  Who will pay docs to do this?  Is this a “Pollyanna” idea?  Can existing IT structures be enhanced or are new/different ones needed

Proposal Suggestions To-Date  Include pharmacists in provider team as most aged & disabled are involved w/one  Add training on risk avoidance: falls, diet, meds, onset of illness & physical changes report to MD

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

CMS Demos To Test Provider- Based FFS Care Management  Support primary/specialist collaboration  Enhance clinical information communication  Increase adherence to evidence-based care  Reduce unnecessary hospital and ER use  Avoid costly and debilitating complications

Cultural/Diversity Issues  Rural: access to care, in-home care, transportation  ADA accommodations for exam and treatment and physical access  Language/culture: –Need more culturally diverse professionals –MDs and translation assistance: availability, cost issue –Can extender staff be competent & responsible in this area?