1. Long-Term Care Integration in San Mateo County Jean Fraser Maya Altman Maya Altman March 10, 2011

2. Long-Term Care Integration Core Concepts ► ► Emphasize home and community-based services to allow individuals to remain in community settings ► ► Consolidate preventive, primary, acute, Long-Term Care, and Home- and Community-Based services and funding ► ► Allow more local control and flexibility ► ► Eliminate administrative duplication and complexity

3. Core Concepts (continued) ► ► Enhance assessment, care planning, and medical management ► ► Establish smooth and appropriate transitions between levels of care ► ► Reinvest savings back into San Mateo County community ► ► Improve service delivery and access to care

4. Goals: Long-Term Care Integration ► Person-centered care ► Improved health & quality of life ► Greater access to home and community-based services ► Lower number of premature nursing home placements

5. Current Situation 80 year old Living alone Multiple chronic health problems Declining at home Socially isolated Chronic lack of support leads to hospitalization Discharge to nursing home No coordinated care Person unable to reside at home alone Result Lack of long-term planning Lives in an institution Very expensive care Barriers

6. Future of Long-Term Care 80 year old Living alone Multiple chronic health problems Declining at home Socially isolated Primary care providers connect with case manager for long-term care assessment Services selected based on need and long-term care plan Support provided in the home Result Improved health Lives in most integrated setting More cost efficient

7. Why now? San Mateo County is facing a huge increase in older adults. Minus a fully coordinated system, more people will fall through the cracks.

8. Work Toward Long-Term Care Integration in San Mateo County YearMilestones 1980s and 1990s San Mateo County consolidation of HCBS in Health System San Mateo County consolidation of HCBS in Health System Creation of Commissions on Aging and Disabilities Creation of Commissions on Aging and Disabilities SMC, HPSM, and SMC Hospital Consortium propose LTCI SMC, HPSM, and SMC Hospital Consortium propose LTCI IHSS Public Authority Advisory Committee IHSS Public Authority Advisory Committee 2003 SMC selected as pilot for Uniform Assessment Tool SMC selected as pilot for Uniform Assessment Tool County hospital Senior Care Center Opens (Ron Robinson SCC) County hospital Senior Care Center Opens (Ron Robinson SCC) 2006 HPSM Medicare CareAdvantage operations begin HPSM Medicare CareAdvantage operations begin CareAdvantage subcontract with SMC Behavioral Health and Recovery Services CareAdvantage subcontract with SMC Behavioral Health and Recovery Services 2008 Partnership with CalOptima in Orange County to advocate for LTCI in both counties Partnership with CalOptima in Orange County to advocate for LTCI in both counties 2010 LTC institutional benefit added to HPSM LTC institutional benefit added to HPSM HPSM initiates clinical care management in nursing facilities HPSM initiates clinical care management in nursing facilities

9. 1998: Healthy Families 2006: CareAdvantage SNP 2008: San Mateo County ACE 2010: Long-term Care 2001: HealthWorx 2003: Healthy Kids 1987: Founded HPSM serves 95,000 people through six programs.

10. 59,000 members 42% of whom are seniors and disabled 8,000 of whom are Special Needs Plan members California San Mateo County HPSM Medicaid

11. CareAdvantage (Special Needs Plan) 8,000 enrollees (60% of those eligible) Member benefits –Dental and vision care –Transportation for medically related services –Subcontract with County Behavioral Health Customer service –Staff dedicated to and expert in serving older and disabled members –Staff fluent in Spanish, Chinese, Tagalog, and Russian –Help for members in navigating the Medicaid / Medicare maze –Assistance in maintaining Medi-Cal status <1,000 people “saved” from losing Medi-Cal in past year Work with Legal Aid to help people with share of cost

12. CareAdvantage (con.) Care management –Identification of members at high risk –In home physician visits –Help with managing medications –Care transitions between hospital and home –Connecting members to medical homes –Interdisciplinary care coordination teams –Case conferences with County Behavioral Health and Aging and Adult Services / IHSS –Clinical management in long term care facilities

13. Medicaid Funded Services Acute Medical / Ancillary Care (HPSM/County) Institutional Long Term Care (HPSM as of Feb 2010) Home & Community Based Services (Many operated by County/FFS) Outpatient/Clinic Based Primary Care Distinct Part Skilled Nursing Facilities In-Home Supportive Services (IHSS) Specialty Medical Care/ County Mental Health Services Freestanding Nursing Homes Multipurpose Senior Services Program (MSSP) Ancillary Services (Lab, pharmacy, radiology, durable medical equipment) Caveat: Reimbursement only with LTC aid code Hospice, Adult Day Health Care, Adult Day Care, Alzheimer’s Day Care Resource Centers Inpatient Services

14. Services combined into LTCI Skilled Nursing PACE MSSP In-Home Care Adult Day Care Nutrition Mental HealthAlcohol & Other Drug Skilled Nursing

15. Model for LTCI ComponentOptions PopulationAll adult Seniors and Persons with Disabilities (SPDs) Medical Criteria Eligible for nursing home level of care At risk for nursing home level of care in the near term CoverageDual eligible enrolled in CareAdvantage Medicaid only Dual eligible not enrolled in CareAdvantage Assessment Uniform assessment tool for all integrated services

16. Model for LTCI — Continued ComponentOptions Acute ServicesAll Medicaid primary and acute care All Medicare primary and acute care for duals in CareAdvantage Long Term Care Medicaid nursing facility services Medicare nursing facility services for CareAdvantage duals HCBSAll Medicaid HCBS:  Adult day health care  Personal care (IHSS)  MSSP “ In Lieu ” Services, e.g.:  Services in assisted living  Services in Board and Care  Expanded Transportation  Home modifications

17. Model for LTCI — Continued ComponentOptions Medical HomePrimary Care Medical Home (enhanced primary care) Interdisciplinary TeamMember specific teams Member is part of the team Personal care worker may be part of the team Individual Care PlanAddress physical as well as psychosocial needs Accessible by all Member involved in development of plan Case ManagementCase management based on individual care plan

18. Model for LTCI — Continued ComponentOptions Community ServicesLeverage existing San Mateo County Health System and community resources Integrate services already available Enhanced Data Single initiative to track and trend interventions / outcomes Public AuthorityContract with Public Authority for personal care services StakeholdersProgram oversight by local stakeholders

19. What Will Be Different? NowLTCI One place to go for help One uniform assessment for all services Variety of options available with focus on keeping people in the most home- like environment System for MD and community agencies to refer patients who need help before they decline & need hospital care Patient is the decision-maker

20. Questions?