Model of Care TrainingWindstone Behavioral Health

Compassion, Courtesy, Respect.

2016

Learning Objectives List the differences between Special Needs Populations (SNP)

and Cal MediConnect (CMC) programs. Understand the key components of the Complex Case

Management Program Understand the key components and the goals of the Model of

Care (MOC) Understand the value of coordination of benefits and services for

the member Explain how the components of the program interact to meet

member needs. Understand the value of coordination of benefits and services for

the member.

Special Needs Plan (SNP) Special Needs Plan or SNP is a Dual eligible

Special Needs plan created as part of the Affordable Care Act to provide extra benefits for members with special care needs.

Medicare primary payor for hospitalizations, ED visits, pharmacy, and short-term skilled nursing care

Medi-Cal pays for non-covered Medicare benefits, also known as “Medi-Cal wrap around benefits” and exhausted Medicare benefits

Cal MediConnect (CMC) Cal MediConnect (CMC) is the official name for the

California duals project, which combines the two benefit packages of Medicare and Medi-Cal into one plan. This plan provides additional coordination of care and services for members.

CMC offers improved access to long-term services and supports, including nursing facility, Community-Based Adult Services (CBAS), In-Home Supportive Services (IHSS) and Multipurpose Senior Services Program (MSSP).

Different from SNP as increased care coordination and reporting requirements.

Complex Case Management Program High risk care coordination/case management will

be available to members through the Medical Group who have a need for more intensive monitoring and follow-up (e.g., have multiple chronic diseases, behavioral health needs).

The APA’s (American Psychiatric Association) clinical guidelines for treatment plans for High Risk patients include intensive follow-up activities post discharge from inpatient treatment.

Complex Case Management Program (continued)

The goals of the Complex Case Management Program include: Improving and maintaining functional BH and medical health

status; Enhancing coordination across specialties and settings; Eliminating duplicate services; Improving member safety Linkages to and coordination with community-based services

and Reducing avoidable psychiatric and medical complications,

emergency room use and hospitalizations; and, arranging services that promote community living among others.

What is the Model of Care (MOC)? An integrated delivery system that supports:

Care Management Policy Procedures Operational Systems

A member-centric program to support members health and health care decisions

Benefits managed via care coordination, health management and planning

Components of the MOC

Model of Care Elements: Staff Structure

Personal Care Coordinator Health Risk Assessment (HRA) Interdisciplinary Care Team (ICT) Individualized Care Plan (ICP) Coordination of Care Transitions of Care

Personal Care Coordinator (PCC) Personal Care Coordinators (PCC) are employed by the health

networks and medical groups (Not WBH). PCC Role:

Assist the member with telephonic and in-person completion of the HRA

Function as the member’s primary point of contact at the health network

Support the member in accessing and using the health care system

Assist with scheduling appointments Notify the health team regarding triggers or key events to ensure

real time response Work with case management to resolve access, medical and

psychosocial issues

Health Risk Assessment (HRA) Survey/Assessment conducted by the Medical Group (not WBH). An adjunct to the primary care provider’s (PCP) history and

physical Purpose:

Uncover problems Detect barriers to progress or completion of goals Offer providers actionable information Facilitate the planning process:

Development of an initial care plan (ICP) using HRA findings Identification of potential Interdisciplinary Care Team (ICT) members Development of a finalized individualized care plan (ICP)

HRA (continued)

Identify key member accommodation needs: Physical Cultural differences Language Alternative formats Health literacy

Identify a member’s care management level: Basic Care coordination Complex

Categorize member’s needs: Medical (acute and chronic) Behavioral health LTSS Access Coordination of services Health monitoring

Interdisciplinary Care Team (ICT) (Continued)

Interdisciplinary Care Team (ICT): Driven by and coordinated by the Medical Group (not

WBH). An ICT must be offered to every member and a member

must have access to an ICT, if requested. Member-centered and built on member specific

preferences and needs. High-risk members will have the most complex ICTs, which

may include a broader range of participants. Deliver services with transparency, individualization,

respect, linguistic and cultural competence and dignity.

Interdisciplinary Care Team (ICT) (Continued)

Core Participants Possible Additional Participants

Member/Authorized Rep Medical Director

Disease Management

Coach

PCP Pharmacist LTSS Coordinator

PCC

Behavioral Health

Specialist Family Discharge Planner

Specialist, as indicated Social Worker Therapist

Case Manager Dietitian Community-Based Organization (s)

Individualized Care Plan (ICP) ICT results in a finalized ICP that includes the

member’s prioritized goals and potential barriers developed by all ICT participants.

Dynamic and person-centered plan of care for all members: Includes comprehensive input from the member, member’s

caregiver, PCP, specialists and other providers according to member’s wishes

Identifies member strengths, capacities and preferences Provides additional care options, including transitions of

care settings Identifies long-term care needs and the resources available

Individualized Care Plan (ICP) (Continued)

ICP key elements include: Prioritized goals that take into account:

Member/caregiver’s goals or preferences Member/caregiver’s desired level of involvement in case management plan

Barriers to meeting goals and complying with plan Self-management plan Resources to be utilized, including appropriate level of care Planning for continuity of care, including transitions/transfers Scheduled time frame for re-evaluation Assessment of progress towards goal, with modifications as needed Collaborative approaches, including family participation

ICT recommendations and ICPs are provided to the member, the PCP and other members of the ICT.

Member’s ICP must be developed within the required time after health risk assessment is completed.

Individualized Care Plan (ICP) (Continued)

Health network reassesses member with health status changes or key events: Changes in care settings:

Hospitalization (observation or inpatient) Outpatient surgery SNF admission Emergency room visits Changes to LTSS level

New behavioral health referral or admission Reported alteration in mental/functional status Multiple falls Unsafe home environment Pharmacy referral, drug interactions or new member transition

Coordination of Care Medical Group PCC’s coordinate members’

care across the full continuum of service providers.

Focus is on providing services in least restrictive setting, and the care provided is person-centered, outcome-based approach.

Care Coordination is performed by nurses, social workers, PCPs, and other medical, Behavioral Health, or LTSS professionals and health plan care coordinators as appropriate.

Transitions of Care Definition:

Coordination of services and care from one care setting to another Goal:

Assisting the member to remains in least restrictive setting Process:

PCC and/or care manager coordinates care: Assists with the transfer of clinical records Assists with identification of needed providers or facilities Facilitates reconvening of ICT Facilitates updates to ICP to reflect new provider, facility, or services and care

needs Communicates ICP between the sending and receiving settings, ICT and

member/caregiver/authorized representation within one business day of notification that transition occurred

Sends ICP by faxing, mailing or electronic medical record transfer or face-to face hand-off to member

Continuity of Care (Continued)

Benefits can continue, provided all criteria are met: Up to 6 months for primary and specialty Medicare services Up to 12 months for Medi-Cal services Special rules for pharmacy Special rules for overlapping benefits Special rules for members residing in a nursing facility

General criteria: Evidence of an existing relationship with provider The member has been seen at least once during the previous 12

months by PCP and at least twice by specialty provider. Provider must accept the plan reimbursement Provider without quality or credentialing issues

Continuity of Care If criteria are not met:

Medical Group must arrange for another provider to render member’s care.

Inform the member of the determination in a timely manner appropriate for the member’s clinical conditions, not to exceed 30 days from the date of the request.

WHS Responsibilities Medical Groups are responsible for obtaining initial information

from Health Risk Assessment (HRA), engaging member and coordinating Interdisciplinary Care Team (ICT) meeting and an individualized Care Plan (ICP) on an annual basis or as needed based on member’s needs or utilization of services.

WHS CM is required to participate in all ICTs for members receiving BH services and WHS assigned case manager will provide appropriate clinical information regarding BH needs. Presented material by WHS in ICTs will include the following: Mental Health (MH) Diagnoses, type, frequency & type of MH

treatment, BH treatment Plan (inpatient, PHP, outpatient care); Psychiatrist prescribed medications, including recent changes or

intent to change; Metabolic monitoring requests/coordination of all lab monitoring;

WHS Responsibilities (Continued)

Answers to PCP BH consultation questions (differential diagnosis, depression/anxiety/psychological factors affecting pain management);

Suggestions for PCP’s BH follow up and/or resumption of care; Recommendation of PCP to provide member SBIRT and appropriate follow

up for members that indicate chemical dependency. WHS CM participant will make recommendations based on member’s

needs, as appropriate, including referrals to LTSS, country agencies, support groups or other services.

ICP will include deliverables for all participants and WHS will complete deliverables within an appropriate time frame or as indicated by the ICP. ICP will outline measureable objectives and timetables to medical,

behavioral health (BH) services or other referrals and recommendations, as discussed in ICT.

WHS CM will communicate with Medical Group PCC on a weekly basis until deliverable is completed.

Integrated Long-Term Services and Supports Long-Term Care (LTC) as a Medi-Cal

managed care plan benefit Community-Based Adult Services (CBAS) as

a Medi-Cal managed care benefit Multipurpose Senior Services Program

(MSSP) as a Medi-Cal plan benefit In-Home Supportive Services (IHSS) as a

benefit Long-Term Services and Supports (LTSS)

Contract Resources CMS National Financial Alignment Initiative NCQA Model of Care Review Process State of California Demonstration Proposal CMS/DHCS CalOptima 3-way Contract CDSS/DHCS CalOptima 3-way Agreement Agreements/MOU with:

Orange County Social Services Agency Orange County IHSS Public Authority Orange County HCA Mental Health Department

DPL 15-001, 15-003, 13-002

Model of Care Training

Thank you!

If you have any questions or comments please contact the WHS Compliance Department complianceshared@windstonebehavioral.com