1. Supportive Housing Network September 23, 2011 1

2.  NYSDOH submitted two draft SPAs to CMS on June 30, 2011  One SPA targeted the Managed Long Term Care population; the other targeted the chronic medical/behavioral health population  The focus of today will be on the SPA targeting the chronic medical/behavioral health population  Available on the NYSDOH Health Home Website at: http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm 2

3. At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition. Chronic conditions include but are not limited to:  mental health condition  substance abuse disorder  asthma  diabetes  heart disease,  being overweight (BMI over 25)  HIV/AIDS  Hypertension 3

4.  Enrollees in the behavioral health category will be identified through claims and encounter data. They often have co-morbid chronic, medical conditions and unmet social needs such as a lack of permanent housing  Enrollees in the chronic medical condition category will be identified through claims and encounter data as having two or three chronic medical conditions – including HIV/AIDS.  The State will use a combination of clinical risk groups (CRG), an algorithm that predicts hospitalizations, and behavioral health indicators to select Medicaid enrollees for health homes. 4

5. All Other Chronic Conditions 306,087 Recipients $698 PMPM Mental Health and/or Substance Abuse 408,529 Recipients $1,370 PMPM Long Term Care 209,622 Recipients $4509 PMPM Developmental Disabilities 52,118 Recipients $10,429 PMPM $6.5 Billion 50% Dual 10% MMC $10.7 Billion 77% Dual 18% MMC $2.4 Billion 20% Dual 69% MMC $6.3 Billion 16% Dual 61% MMC $25.9 Billion Total Complex N=976,356 $2,338 PMPM 32% Dual 51% MMC 5

6. “Medical Home” for Patients with Risk Score ≥50 Based on Prior 2-Years of Ambulatory Use 51% Source: NYU Wagner School, NYS OHIP, 2009. 6

7.  NY will use “designated providers” for the Health Home Program  Designated providers can be: ◦ Managed Care Plans ◦ Hospitals ◦ Medical, mental and chemical dependency treatment clinics ◦ Federally Qualified Health Centers (FQHCs) ◦ Targeted Case Management (TCM) programs ◦ Primary care practitioner practices ◦ Patient Centered Medical Homes (PCMHs) ◦ Any other Medicaid enrolled entity that meets NY’s health home requirements ◦ Considering adding other long term care providers 7

8. Section 2703 of the Patient Protection and Affordable Care Act (ACA) provides states, under the state plan option or through a waiver, the authority to implement health homes. opportunity to address and receive additional federal support for the enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long- term services and supports for persons with chronic illness. provides 90 percent FMAP rate for health home services for the first eight fiscal quarters that a health home state plan amendment is in effect; multiple SPAs permitted. 8

9.  NY is seeking applicants that : ◦ have strong medical, behavioral, and social service community providers connections ◦ use multi-disciplinary teams of medical, behavioral, TCM, and social services providers that can assure appropriate and timely access to services. Each patient enrollee will be assigned a single care manager who is responsible for managing and coordinating their care. There will be only one care plan for each patient enrollee. All members of the health home team will report back to the care manager on patient status, treatment options, actions taken, and outcomes. Health homes will be responsible for reducing or eliminating costs associated with avoidable inpatient and emergency room visits and improvi ng patient outcomes. 9

10.  Must be enrolled (or be eligible for enrollment) in the NYS Medicaid program and agree to comply with all Medicaid program requirements.  Can either directly provide, or subcontract for the provision of, health home services. Responsible for all health home program requirements, including services performed by the subcontractor.  Care coordination and integration of heath care services will be provided to all health home enrollees by an interdisciplinary team of providers, where each individual’s care is under the direction of a dedicated care manager who is accountable for assuring access to medical and behavioral health care services and community social supports as defined in the enrollee care management plan.  Must meet standards for delivery of six core health home services as described in following slides. Must provide written documentation that clearly demonstrates how the requirements are being met. 10

11.  Health home providers will be required to provide the following health home services in accordance with federal and State requirements: ◦ Comprehensive care management  An individualized patient centered care plan based on a comprehensive health risk assessment – must meet physical, mental health, chemical dependency and social service needs. ◦ Care coordination and health promotion  One care manager will ensure that the care plan is followed by coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee’s needs. The health home provider will promote evidence based wellness and prevention by linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services based on need and patient preference. ◦ Comprehensive transitional care  Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care. ◦ Patient and family support  Individualized care plan must be shared with patient enrollee and family members or other caregivers. Patient and family preferences are considered. 11

12.  Health home providers will be required to provide the following health home services in accordance with federal and State requirements: ◦ Referral to community and social support services  Provider will identify and coordinate community and social supports ◦ Use of health information technology (HIT) when feasible  Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation 12

13.  NY will be using quality measures that fall into the following categories: ◦ Measures collected from claims and encounters ◦ Measures currently collected by managed care plans ◦ Measures per NQF and/or meaningful use measures ◦ New measures that meet federal reporting requirements ◦ Referral to community and social support services  Provider will identify and coordinate community and social supports ◦ Use of health information technology (HIT) when feasible  Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation 13

14. 976,000+ high cost/high need Medicaid enrollees (1) Chronic conditions at risk for a 2 nd chronic condition (2) Chronic conditions (1) Serious & Persistent Mental Health Condition Yes *Medically and Behaviorally Complex Non-Compliant with Treatment Health Literacy Issues ADL Status Inability to Navigate Health Care System Social Barriers to Care Homelessness Temporary Housing Lack of Family or Support System Food, Income Need assistance applying for Entitlement Programs Patient Meets Health Home Criteria Assigned a Health Home Patient Assessment* Level I Health Home Services – Moderate Need Level II Health Home Services – Multiple Complex Needs Level III Health Home Services – Intensive Complex Needs Periodic Reassessment * for continuation of Health Home Services Health Home Services Not Required Primary Care Practitioner Manages 14

15. HH MCO/ BHO MCO/ BHO Recipient PCMH CMHC MCO/ BHO MCO/ BHO Recipient Medicaid Agency Other MCO plus provider = HH Contract with HHs MCO/BHO/ACO is HH Recipient 15

16. 16  The State will use a combination of the following to assign Medicaid enrollees to Health Homes: ◦ clinical risk groups (CRG), ◦ an algorithm that predicts hospitalizations, and ◦ behavioral health indicators  Medicaid enrollees will be assigned to a health home, to the extent possible, based on existing relationships with ambulatory, medical and behavioral health care providers or health care system relationships, geography, and/or qualifying condition.  Initial assignments will be for members who qualify for Health Home services but currently do not have a meaningful primary care or case management connection.  Patients will not be moved from their current TCM/COBRA, CIDP, MATS

17. 17  The State will also include any supportive housing services an individual may have in keeping those connections in health home assignments.  Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment.  The State will provide health home providers a roster of assigned enrollees and current demographic service access information to facilitate outreach and engagement.  With the exception of TCMs, where special arrangements may be made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data provided by the state.

18. 18 165 LOIs received ◦Many comprehensive well thought through networks ◦Some concerns about specific network adequacy issues ◦Some LOIs have more comprehensive networks than others ◦Some overlapping regions and partners ◦Some smaller less robust entities that should merge DOH is working with OMH, OASAS and NYCDOHMH to assess network adequacy and suggest additional network partners and any appropriate mergers

19. 19 Phasing in Health Home Implementation:  Phase I -13 counties ◦ Applications due November 1 ◦ Implementation January, 2012  Phase II – Counties TBD ◦ Target Implementation April, 2012  Phase III-Counties TBD ◦ Target Implementation June, 2012

20.  Bronx  Brooklyn  Nassau  Monroe  Warren  Washington  Essex  Hamilton  Saratoga  Clinton  Franklin  St. Lawrence  Schenectady 20

21. 21  Finalizing roles of responsibilities for managed care plans  Targeted Care Management transition  Timing and counties in phases II and III  Network adequacy review and feedback  Final CMS SPA roles (outreach and engagement; quality measures)  Rate adequacy feedback (HIV upweights, etc.)

22.  Housing is one of the key determinants in identifying a member’s need for care coordination  Opportunity for the medical community and supportive housing community to work more collaboratively.  Some Medicaid members in supportive housing will be eligible for Health Home services.  Similar to members in TCM, supportive housing is providing effective and comprehensive care coordination services. 22

23.  More formal arrangements between supportive housing providers and direct service providers to assure care coordination is tethered to direct care services.  Both the supportive housing community and the medical (both physical and behavioral health) community can work towards identifying additional resources for housing and increase housing opportunities  Members in supportive housing eligible for Health Home services can be assigned to Health Homes that include their supportive housing as a partner. 23

24.  Improved patient health outcomes  Reduce inappropriate ED visits  Reduce avoidable hospital admissions and readmissions  Achieve a ROI and ultimate cost savings Increasing the number of publicly insured members will only be possible if we create a sustainable system 24

25.  Speed at which the program is getting launched ◦ Addressing some of that with the phased implementation  Lack of housing slots  Effectuating change at the site of service delivery  Bringing care coordination closer to service delivery 25

26.  NYS Health Home Web site (links to many relevant materials): http://nyhealth.gov/health_care/medicaid/program/medicaid _health_homes/index.htm. http://nyhealth.gov/health_care/medicaid/program/medicaid _health_homes/index.htm  Questions and/or comments regarding New York's implementation of health homes can be directed to hh2011@health.state.ny.us. hh2011@health.state.ny.us. 26