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Published byReynard Parsons Modified over 9 years ago
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Lifemark Long Term Care Experience December 15, 1999
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The Lifemark Mission n Through innovative care management services and technology offerings, Lifemark strives to create fundamental change in the well being of vulnerable, frail, elderly and chronically ill people.
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Locations Phoenix, AZ (Corporate Office) Albuquerque, NM Fort Smith, AR Honolulu, HI Houston, TX Indianapolis, IN Lansing, MI San Diego, CA
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LIFEMARK CORPORATION Care Management Strategies for “At Risk” Populations December 1999
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Aging Population Longer Life Expectancies Prevalence of Chronic Conditions Complex Benefit Coordination Why is Long Term Care (LTC) a heightened issue?
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The Coordinated Model Integrated Services n Long Term Care n Home and Community Based Services n Behavioral Health n Medical Care Services: l Inpatient/Outpatient care l Physician l Lab/Radiology l EPSDT l Transportation l Ancillary Services l Specialist l Pharmac y l DME l Therapies “Single Entity” LTC HCBS Behavioral Health Medical Care Svcs n Coordinated Medicare fee-for-service and/or Medicare HMO Benefits
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Coordinated LTC Model Full Continuum of Placement Options Most Restrictive Least Restrictive Assisted Living/ Residential Care Adult Foster Care Home Adult Care Home Home or Apartment Specialty Unit within a nursing facility Skilled Nursing Facility
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Patient Centered Care Case Manager’s Role n Nurses, Social Workers, or those with 2 years case management experience n Coordinator, facilitator, investigator, service broker, liaison, and advocate who is empowered to authorize and verify services n Leads team of decision makers Patient Family or Representative Case Manager PCP n Closely linked to PCP, patient and family
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Care Management Systems Initial In-Depth Assessment n Highly automated using laptop computers n Performed within five days of enrollment n Current/previous medical status n Socioeconomic profile n Psychological assessment n Functional assessment (ADLs) n Develop multiple alternative care plans for service(s), placement, provider, and/or reassessment schedule n Level of care determination n Perform cost effectiveness study n Initiate/authorize: l Formal service plan l Actual placement l Establish measurable goals Care One
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Care Manager Scope of Authorization n LTC Services/Placements include n Nursing Facility n Assisted Living/Personal Care Home/Adult Foster Care n Adult Day Care n Community based alternatives n Medical Supplies/DME n Value Added Services n Home Services n Personal, Attendant, and Chore Services n Skilled Home Health Care/Short term therapy n Emergency Response Systems n Meals on Wheels n Respite
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Patient-Centered Care Critical Elements to Success n Develop intense, fully integrated care management system to consolidate funding, limit fragmentation/duplication, monitor quality, outcomes, clinical utilization and costs n Establish an HCBS infrastructure and expand covered services to include full menu of HCBS services n Perform outcomes, placement and cost comparisons for effective service alternatives
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Arizona/Texas LTC Program(s) n State Medicaid Agency Retains Responsibility For: l Determining Member Program Eligibility (Both Financial and Medical) l Health Plan Assignment l HCFA Waiver/State Regulations l Program Compliance Monitoring/Auditing l RFP Development, Scoring and Awards
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Ventana Health Systems A Wholly Owned Subsidiary of Lifemark Corporation n Arizona Health Care Cost Containment Systems’ Long Term Care System (ALTCS) program contractor since January 1989 n Serving the most chronically ill of the Aged, Blind and Disabled at- risk for nursing home placement n Providing services in 9 rural counties of Arizona n Pre-paid, capitated health plan for 1,900+ LTC members n A fully integrated services approach coordinating institutional, home and community based services, behavioral health, pharmacy and medical care services n Member satisfaction indicates improved functionality and quality of life Arizona
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Percentage of Lifemark/Ventana Health Plan Members in Institutional vs. HCBS Settings Source: Ventana Health Systems Claims and utilization data. Impact on Member Placement Movement Toward Home and Community Based Services
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Ventana Health Systems A Wholly Owned Subsidiary of Lifemark Corporation Caseload limits are (case manager-to-member ratios): n 1/48 HCBS, acute care/hospice members (visits every 90 days) n 1/120 nursing facility members (visits every 180 days) n One case manager for mixed caseload of approximately 96 clients (nursing facility and HCBS) n Ventilator dependent members case managed based on setting Subset of Clinical quality outcomes are monitored by measuring: n Influenza n Sacral/Coccygeal pressure ulcers n Hospitalization and emergency room utilization n Activities of Daily Living n Fractures related to falls Arizona
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n Pilot demonstration started in Harris County (Houston), Texas January 1998 n Integrates acute medical, LTC, behavioral and community based services into a managed care delivery system n Emphasis on least restrictive setting and intensive care coordination n Three health plans awarded contracts, covering over 52,000 members n Primarily mandatory enrollment n Lifemark manages over 19,700 LTC (NF and CBA) and SSI (ABD) recipients - the largest in the STAR+PLUS program HMO BLUE/STAR+PLUS 100% Administered Managed by Lifemark Corporation Texas
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HMO BLUE/STAR+PLUS Managed by Lifemark Corporation Caseload limits are determined by need (case manager/member ratios): n Level I - 1/2,500 members n Level II - 1/250 members n Level III - 1/100 members n Level IV - 1/30-60 members Current clinical quality outcome studies are: n Depression n Childhood asthma n Adult diabetes n Breast cancer screening Texas
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