San Diego Long Term Care Integration Project Planning Committee Presentation September 10, 2003

Community Planning Process n From 50 to 400+ key stakeholders over past 4 years: 10,000 + hours n Seeking to improve system of care for consumers and providers 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 –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

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

Why change? n To align incentives for optimum care across the continuum n To impact quality of life for aged and disabled, especially high cost users n To respond to demographics that require Medicare to respond to chronic care needs n To shift focus to consumer and outcomes n To respond to Olmstead Decision

Mrs. C n 84 year old woman lives alone n CHF, HTN, diabetes, hearing and vision loss, IADL dependencies n 16 medications by 6 MDs n Medicare and Medi-Cal beneficiary n Only child lives in Chicago

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 n Since then: Dr. Mark Meiners assists w/strategies development: –Network of Care –Physician Strategy –HSD Health Plan/Pilot Projects

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

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

Health Plan Pilots n Pilots to do small, voluntary models of care integrated across the health, social, and supportive services continuum: –State to contract with private entity if stakeholders agree –Healthy San Diego Health Plans to develop pilot with consultant resources

New Parallel Initiatives n Medicare reform: Drugs and Duals n CMS “chronic care” M+C demos n SHMOs and “special needs” plans n AB 43 in California and LTCIP pilot n Medi-Cal and disease management n PACE in San Diego n Mass. Senior Care Organization

Consultant Team for HP Strategy n Dr. Mark Meiners, National Program Director, RWJ Medicare/Medicaid Integration Program n Dave Ogden, Milliman USA n Charles Birmingham and Karin Kalk, Health Plan Consultants n LTCIP Staff and Stakeholders

Consultant Proposal Long Range n 95,000 have 2 choices –Physician Strategy MD incentives Support for chronic care Across Medicare/Medicaid –HSD+ NF & “certifiable” duals Aged, then younger Then all HSD ABDs Then all ABDs

Consultant Proposal Funding n Who? –HSD plans that meet requirements –With or without current Medicare participation –May subcontract for LTC –Care management must be overarching n Medi-Cal –Acute, LTC, IHSS, 1915(c) waiver n Medicare –Waiver to allow HSD to serve duals w/cap –“demo” status to add “frailty adjuster”

Actuarial Consultant “Scenarios” n Scenario A –Initial, moderately managed utilization –16% of Medicare payment available for admin, profit, HCBC n Scenario B –More developed, managed utilization –22% of Medicare payment available for admin, profit, HCBC

Key Program Components n Common entry point: intake, risk screens, and needs assessment n Care plan development: electronic assessment and C-E triggers n Care coordination standards: contracted to gain CQI via team care approach n Common data: risk assessment, point of service PDA, data warehouse n Network development support: HCBS focus

Proposal issues already identified n Physician Strategy diminishes HSD plans’ potential provider network capacity n Younger disabled do not appear to be financially “attractive” n What to do re: mental health?

Next Steps n Health Plan and Stakeholder input on Consultant Proposal n Develop Administrative Action Plan (Jan. ’04) –NOC (AoA/CMS funding?!) –Physician Strategy (CA Endowment $$) –Health Plan Pilots: HSD & AB 43 n Stakeholder consensus (Feb. ’04) n Board of Supervisors approval (Mar. ’04) n Examine new federal initiatives

How to influence planning? n Get on LTCIP mailing list for updates n Log onto website for background & info: n Call or input/ideas: or