Examining Integrated Care: Challenges and Opportunities · Examining Integrated Care: Challenges...

Research Report

Examining Integrated Care:

Challenges and Opportunities

A White Paper Commissioned by the

Washington Association of Area Agencies on Aging

Prepared by Penny Black and Kathy Leitch

CE REED AND ASSOCIATES

October 2011

Consultants’ Note:

The Governor’s 2011 Health Innovation for Washington proposal sets a goal of

reducing the trend in health care spending in Washington. To achieve this goal, the

State proposes to change health and long-term care benefit designs,

delivery models and payment methodologies.

W4A White Paper: Examining Integrated Care

CE Reed & Associates – October 2011 Page 2

Table of Contents Executive Summary .................................................................................... 3

Introduction ................................................................................................ 4

Why Integrate Health and Long Term Supports? ............................... 4 Long-Term Supports and Services: A Significant Expenditure ............ 4

The Need for Integrated Care ............................................................ 5 The Governor’s Goals for Health Reform ............................................ 7 WA Proposal to Integrate Care for Dual Eligibles ............................... 9

Stakeholder Processes for Development of Integrated Care ............ 10

A Survey of the Landscape: Results of Key Informant Interviews ............. 12

Views of Governor’s Staff, Legislators and Their Staff ..................... 12 Views of Key State Management Staff .............................................. 13 Views of WA Health Plans/Providers ............................................... 14

A Survey of the Landscape: Results of Research and Trends ..................... 16

WA State Innovations: AAA Models for Integrated Care .................. 16 Lessons from States Similarly Situated to Washington .................... 20

Key National Organizations and Research Studies ........................... 24

A Detailed Analysis of Key Recommendations: .......................................... 27



Executive Summary This report was commissioned by the Washington Association of Area Agencies on Aging to analyze the environment in Washington State in light of the objectives of the Affordable Care Act. Governor Gregoire’s 2011 Health Innovation for Washington proposal sets a goal of reducing the overall trend in health care spending in Washington. To achieve this goal, the State proposes to change health and long-term care benefit designs, delivery models and payment methodologies. This document is intended to assist the Area Agencies on Aging in planning for their participation in a coordinated and integrated acute and long term care system. Most Medicaid beneficiaries who need long term supports and services receive their care through a fragmented fee-for-service system. As a result, costs of long term supports and services continue to rise, accompanied by increased demand due to the growing population in need of these services and supports. The current system lacks sufficient care coordination for the comprehensive services needed, which then inhibits access to critical services, particularly community-based services, and encourages cost-shifting between providers and payers. These factors are motivating states (Washington included) to look for ways to offer consumers broader access to home and community-based options. In order to develop meaningful recommendations for future roles in integrated care, the authors of this report reviewed national policy research and federal and state policy directions. Interviews were also conducted with key decision makers in Washington State who are developing new approaches to integrated care and with staff of national organizations and other states that have designed integrated care systems that include existing local providers in the delivery of services. The following recommendations include actions for advocacy on behalf of consumers in the development of the integrated system as well as potential opportunities for partnerships with health plans and the health provider network in a newly designed integrated system. Recommendation 1: Actively Participate in the Stakeholder Processes - In the current integrated care discussion, it is important for the state to organize a robust stakeholder process. AAAs should play an active role in the various stakeholder processes associated with the state’s redesign efforts (WA Health Innovation, HB 1738, and the Dual Eligibles Planning Grant.) Recommendation 2: Advocate for Adequate Consumer Protections for Long Term Supports and Services - AAAs should advocate for a number of consumer protections that must be addressed in any new integrated health care system, including provisions for (1) a comprehensive, standardized, independent assessment, (2) independent, multi-disciplinary case (care) management and (3) independent quality oversight and care monitoring. Recommendation 3: Take Demonstrations/Pilot Projects to Scale Statewide - Care Transitions, Chronic Care Management and Chronic Disease Self-Management projects, managed locally by Washington’s Area Agencies on Aging, represent demonstrations and innovations that improve health outcomes and serve as models for integrated care. These model efforts should be incorporated into the statewide design of integrated care. Recommendation 4: Build Strong Connections and Partnerships with the Health Care System – AAAs need to educate health care providers and health insurance plans on innovative AAA service models and the roles that AAAs can play in serving clients who need long term supports and services as part of their health plans.



An Introduction to Integrated Care:

Why Integrate Health Care and Long-Term Supports? The Federal and State governments have become increasingly interested in better

managing the dual eligible population, those who are both Medicare and Medicaid eligible. Dual eligible individuals comprise a high percentage of expenditures. In 2008, the 9.2 million people nationally who were eligible for both Medicare and

Medicaid were more likely to have:

Mental Illness Limitations in Activities of Daily Living Multiple Chronic Conditions

Very few of these dual eligible individuals are now being served by coordinated care

models and even fewer are served in integrated models that align Medicare and Medicaid.

The care for consumers who are dual eligible in Washington is fragmented, unmanaged and uncoordinated at the program level. Different eligibility and

coverage rules contribute to these problems. The current system lacks sufficient care coordination and integration for the comprehensive services this population needs, thus inhibiting access to critical services, particularly community-based

supports, and encouraging cost-shifting between providers and payers.

All of these factors adversely affect this population’s quality of care and health outcomes and contributes to Washington’s and the federal government’s health care budget problems. To integrate services in a comprehensive manner, health

care services must be coordinated with long-term supports and services in a cost-effective way, taking full advantage of the infrastructure that the State of

Washington has created. Through the local Area Agencies on Aging, Washington has a well developed case management and delivery system for long-term

supports, and it should be given serious consideration when talking about primary care, acute care or other health care initiatives.

Long-Term Supports and Services: A Significant Expenditure

Costs of long term supports and services grew from 4.7% of all expenditures in

Washington State in FY99/01 to 5% in FY09/111. Policymakers have invested in many program improvements over this time period that have or are expected to

enhance care. Caseload growth experienced over this period means that more individuals have access to needed services, but as policymakers look toward the future, the population 65+ is forecast to grow by 74% by 2030 and the population

1 LEAP website



85+ is expected to grow by 65%2. The growth in the aging population most likely to need long-term supports will put even more upward pressure on the state

budget.

Additionally, Washington State’s medical costs grew from 14.6% of all expenditures in FY99/01 to $15.6% in FY09/113. In the context of an FY11/13 budget, in which $4.6 billion in budget reductions had impacts on all areas of state government,

policymakers must find ways to improve the cost effectiveness of programs. Integration of health care and long-term supports is seen as an opportunity to

improve client outcomes, reduce duplicative and unnecessary services and bend the growth curve in state expenditures.

The Need for Integrated Care

Many dual eligible consumers have complex care needs, but most lack access to integrated care systems that approach care delivery from a holistic, person-centered perspective and that promote care management and care coordination.

Most consumers do not receive managed/integrated care under current program rules. Care provided by doctors and hospitals is usually not coordinated with long-

term supports provided in the community.

The Patient Protection and Affordable Care Act (ACA) was designed to not only increase access to health care for the American public but also to create opportunities for improving care for dual eligible individuals. The legislation brings

together Medicare and Medicaid and provides opportunities to improve service delivery and financing for this population. It creates new offices within the Centers

for Medicare and Medicaid Services (CMS) to support advancements in care for the dual eligibles: the Federal Coordinated Health Care Office and the Center for Medicare and Medicaid Innovation. The ACA also supports the development of

accountable care organizations (ACOs), a new entity for integrated care. There are high expectations that changing the health care delivery system for Medicare

beneficiaries as well as dual eligible individuals will help achieve the “Triple Aim” under the leadership of Don Berwick (CMS): 1) improve care by focusing on safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity, 2) improve

health by addressing root causes of poor health, e.g. poor nutrition, physical inactivity, and substance abuse, 3) reduce per capita costs.

In a report entitled, “Medicare Spending and Use of Medical Services for Beneficiaries in Nursing Home and Other Long Term Care Facilities: A Potential for

Achieving Medicare Savings and Improving Quality of Care,” the Kaiser Family Foundation (KFF) concluded that beneficiaries living in long-term care facilities

account for a disproportionate share of Medicare spending, with relatively high rates of hospitalizations, emergency room visits, skilled nursing facility admissions and other Medicare-covered services. The relatively high Medicare spending is incurred

not only by long-term care residents who die within the year and those who

2 OFM website

3 Ibid



transition from another setting into a long-term care facility, but also by the individuals living in a facility throughout the year.

The Kaiser Family Foundation (KFF) further indicated that 30% to 67% of

hospitalizations among facility residents could be prevented with well targeted interventions. KFF states that successful efforts to reduce the rate of preventable hospitalizations could yield savings to Medicare. Such efforts, if carefully

implemented, could also help to improve the quality of patient care for Medicare’s oldest and most frail beneficiaries.

Last year, the Center for Health Care Strategies produced three “Profiles of State Innovations” to help states explore and understand emerging options, best

practices and proven models of success in three areas: 1) rebalancing long-term services and support (LTSS) options to support home and community-based

services, 2) developing and implementing a managed LTSS program and 3) integrating care for adults who are dual eligible for Medicare and Medicaid. The current status of a state’s medical and long-term services and support programs

provided the focus for different strategies that were suggested. The best fit for Washington State is the strategy that suggests that states with both strong medical

care systems and a strong LTSS program should consider bridging these systems to integrate services.

The Center for Health Care Strategies (CHCS) published a 2010 paper entitled “Profiles of State Innovation: Roadmap for Managing Long-Term Supports and

Services” that stated that services are disconnected and financially misaligned but that integrated systems are within the reach of states if they:

Build on existing experience and/or infrastructure, Provide a flexible set of benefits and more choice particularly in home and

community-based services, Achieve cost effective services,

Strengthen quality of care and, Fully integrate the delivery and financing of a full range of acute and long-term

supports and services.

According to CHCS, the Kaiser Family Foundation and Thomson Reuters, the

following criteria must be met for successful integration: Assessment, determination of need and case management is independent of

providers, State collects and analyzes data for performance measurement and to track

utilization and costs, Consumers and other stakeholders are engaged in program design and quality

monitoring,

State has formal and informal bridges across medical/LTSS systems.



The following chart highlights the fiscal issues for health care purchasers in serving individuals who are dual eligible for Medicare and Medicaid.

Dual Eligibles account for a disproportionate share of Medicare & Medicaid spending

C.E. Reed & Associates, May 25, 2011

Source: Kaiser Family Foundation, January 2011

8

Medicare Dual Eligibles (2006) Medicaid Dual Eligibles (2007)

Duals, 21%Duals, 36%

Medicare only, 79%

Medicare only, 64%

Share of Population Share of FFS Spending

Duals, 15%

Duals, 39%

Medicaid only, 85%

Medicaid only, 64%

Share of Population Share of Spending

The Governor’s Goals for Health Reform and Integrated Care

Governor Gregoire has set a goal (Washington State Proposal, Health Innovation for Washington 2011) of reducing the trend in health care spending in Washington to

no more than 4 percent annual growth by 2014, while still maintaining or improving patient health outcomes. To achieve these goals, the State proposes to change benefit design, delivery models and payment methodologies.

The State’s strategic objectives to reform the system while containing costs and

promoting high quality care are the following:

Emphasize evidence-based health care: Use of medical devices and treatments demonstrated through study to be safe and effective.

Promote prevention, healthy lifestyles and healthy choices: Washington’s public

health system has shifted priorities from chronic disease management to disease prevention.

Better manage chronic care: Five percent of patients and six conditions (heart conditions, mental disorders and substance abuse, asthma, and chronic obstructive pulmonary disease, type II diabetes, and musculoskeletal conditions)

account for 50% of health care costs. By targeting both the prevention and the treatment of these conditions, efforts to improve care and lower costs are

enhanced. Create more transparency in the health system: Provide information to

consumers to help them decide what the various options for treatment are and

which treatments have proven to be the most effective.



Make better use of information technology: Provide up-to-date information to consumers through the “Health Record Bank”, the “State Health Information

Exchange” and the “Cooperative Agreement Program”.

The chart below illustrates the need to better manage chronic care and the Governor’s five health care goals.

The 5% of Medicaid clients with the highest service costs account for the majority of expenditures.

C.E. Reed & Associates, May 25, 2011 9

Top 5% of Medicaid

Clients Drive 55% of

Expenditures

Expenditures

driven by other 95% of Medicaid

clients

FFY 2008 Medicaid Expenditures

Source: CMS March, 2011 – CMS Analysis of MSIS data, FFY 2008

Of particular importance in the Governor’s proposed reforms are those related to service delivery systems. Actions targeted by the State include:

Nurse and MSW care managers, either as care coordinators or care management

teams, Training and technical assistance in evidence-based screening and treatment of

mental illness and substance abuse and interventions for chronic medical

conditions, Health teams that incorporate public health nurses, community health workers

and others to coordinate care, “Secondary health homes” to include home care, housing, employment, personal

care, oral health, food assistance and coordination with educational and criminal

justice systems, Implementing the “Integrating Care for Dual Eligible Individuals” project that will

pilot methods of sharing savings, coordinating care and integrating primary and secondary health home supports for the dual eligibles (the State’s recently awarded CMS “Planning Grant”),

Combining public financing to coordinate medical, behavioral health and long-term services and supports.



Washington State Proposal to Integrate Care for

Dual Eligible Individuals

Washington State has applied for and received $1,000,000 from CMS to plan for the implementation of a multi-phased design for service delivery and payment models

that align Medicare and Medicaid acute, behavioral and long-term supports and service for dual eligible individuals.

Phase 1 (2012): Expand existing chronic care management models and implement the model statewide.

Phase 2 (2012 procurement): Transfer categorically needy aged/ blind/disabled population from fee for service to full managed care.

Phase 3 (2016-17): Fully integrated delivery and financing systems of care for all dual eligibles.

The State expects to improve access and quality and to reduce Medicaid and Medicare expenditures by:

Expanding chronic care management (CCM), Increased enrollment in integrated medical and behavioral health managed care,

Incorporation of PRISM risk modeling, Inclusion of a health home,

Bundled payments. Chronic Care Management will include:

Patient Activation Model,

Self-management training/coaching, Transition care elements, Motivational Interviewing training,

Capitated payments for disease prevention and health promotion.

The State has identified that a critical component of the planning effort will be the involvement of stakeholders in various levels of program development. The stakeholder process for this project aligns with other stakeholder activities

associated with current health system reform efforts. Those processes are outlined in the next section.



Stakeholder Processes for Development of

Integrated Care in Washington State There are at least four main areas where engagement of stakeholders is mentioned

as the state develops it plan to implement integrated care.

1. Through the passage of HCR 4404, the legislature extended its Joint Select Committee on Health Reform Implementation through 2014. 4404 specifically mandated “an advisory committee to provide advice and recommendations to

the department of social and health services and the health care authority in the development of its implementation plan required by HB 1738 to coordinate the

purchasing of acute care, long-term care and behavioral health services.”

2. HB 1738, Section 116 (1) requires “by December 10, 2011, the department of social and health services and the health care authority shall provide a preliminary report, and by December 1, 2012, provide a final implementation

plan, to the governor and the legislature with recommendations regarding the role of the health care authority in the state’s purchasing of mental health

treatment, substance abuse treatment and long-term care services, including services for those with developmental disabilities. (2) The report shall: (a) consider options for effectively coordinating the purchase and delivery of care

for people who need long-term care, developmental disabilities, mental health, or chemical dependency services. Options considered may include, but are not

limited to, transitioning purchase of these services from the department of social and health services to the health care authority, and strategies for the agencies to collaborate seamlessly while purchasing services separately; and (b) Address

the following components: (i)Incentives to improve prevention efforts; (ii)Service delivery approaches, including models for care management and care

coordination and benefit design, (iii) rules to assure that those requiring long-term care services and supports receive that care in the least restrictive setting appropriate to their needs; (iv)systems to measure cost savings;

(v)mechanisms to measure health outcomes and consumer satisfaction, (vi)the designation of a single point of entry for financial and functional eligibility

determinations for long-term care services; and (vii) process for collaboration with local governments. (3) In developing these recommendations, the agencies shall: (a)consult with tribal governments and with interested stakeholders,

including consumers, health care and other service providers, health insurance carriers, and local governments; and (b) cooperate with the joint select

committee on health reform implementation established in House Concurrent Resolution No. 4404 and any of its advisory committees. The agencies shall strongly consider the guidance and input received from these forums in the

development of it recommendations. (4) The agencies shall submit a progress report to the governor and the legislature by November 15, 2013, that provides

details on the agencies’ progress on purchasing coordination to date.”

3. CMS Planning Grant - Integrate Care for Dual Eligibles awarded to Washington State includes a stakeholder section in the key tasks of the work plan. The work includes developing a plan (focus groups, surveys, forums, work sessions);



consumer and stakeholder outreach/feedback for design, implementation, evaluation; analysis of previous stakeholder work products and current survey

work; focus groups of employees, consumers, tribal nations, etc.; as well as developing the implementation and sustainability strategy with stakeholder,

community input. According to state staff working on the grant, the state will try to coordinate these stakeholder processes to eliminate duplication of effort.

4. Washington State Proposal for Global Medicaid Modernization Initiative (now called Health Innovation for Washington) includes a section entitled

“Stakeholder Involvement”. This section states that “as Washington State engages with HHS/CMS in negotiating a Global Medicaid Modernization Initiative, it will seek the input of Medicaid consumers and their representatives, Tribes,

public and private providers including health plans and Regional Support Networks, other public purchasers, local government and the general public.

Stakeholder work has already begun around better integration of behavioral and physical health across the Medicaid delivery system, engaging counties around the critical role they play in the delivery of “wrap around” services such as

housing and employment and early discussion with the Developmental Disabilities and Long Term Care Communities on health reform and the roles

they play in the health care delivery system of the future…… An organized process for receiving input from and transmitting information to stakeholders

will be initiated. Frequent opportunities for review and input including use of focus groups and opportunities to comment on draft materials will be provided. …”



A Survey of the Current Landscape for Integrated Care:

Results of Key Informant Interviews

Views of Governor Gregoire’s Staff, Washington State Legislators and Legislative Staff:

Interviews were conducted with staff in the Governor’s office, state legislators and legislative staff who will be participating in significant ways in the development and

implementation of Washington’s integrated managed care approach. The Governor’s staff looks to the state’s Health Innovation planning grant as a

focus for determining how long-term supports and services and acute care will be organized in the future. At the same time, the CMS Innovation Center initiative

includes references to the dual eligible planning grant. The Governor continues to emphasize coordination to reduce the rate of growth in health care spending. The Governor’s staff understands the importance of the total array of service options

needing to be included in an integrated system. The movement of the Medicaid state agency to the Health Care Authority is about purchasing health care

differently - the expectation is that managed care plans will be responsible for integrating care.

The Washington State Legislature has no specific plan or model at this time for the implementation of integrated health care. Legislators appreciate the importance of

long-term services and supports as part of an integrated system and especially see the need to integrate health records. They want the dual eligible individuals to be included in the implementation of the integrated health plan. Legislators recognize

that Washington has a well developed home and community-based system, and they are interested in seeing local providers as part of the stakeholder process and

as part of the final model. Legislators emphasized the dialogue with local medical providers and see the importance of medical homes and team approaches to integrating care. They support the concepts of hospital transitions, chronic care

management, client coaching, self-management and “help buddies.”

Interim work for legislative staff will include a focus on SHCR 4404 and HB 1738. 4404 will continue the Joint Committee on Health Reform Implementation and mandates that “the joint committee shall establish an advisory committee to

provide advice and recommendations to the department of social and health services and the health care authority in the development of its implementation

plan required by HB 1738, laws of 2011, to coordinate the purchase and delivery of acute care, long-term care and behavioral health services.” HB 1738 requires the

Department of Social and Health Services and the Health Care Authority to provide a preliminary report by 12/10/2011 and a final implementation plan to the Governor and the legislature by December 2012. Recommendations regarding the

role of the Health Care Authority in the state’s purchasing of mental health treatment, substance abuse treatment, and long-term care services, including

services for those with developmental disabilities, must be included in the report.



Legislative staff agreed that stakeholder input into both processes will be critical to designing an effective plan for integrated care.

Views of Key Washington State Management Staff All state agency staff who were interviewed agreed that the goals for health care

reform and integrated care in the State of Washington are: 1) better outcomes for consumers, 2) enhanced accountability, 3) cost containment, and 4) person-

centered planning and care. Although there have been demonstrations of managed care in Washington, i.e.

PACE and WMIP, those demonstrations fall short of providing the answers for integrated managed care. PACE is a good example of successful integrated care,

but because of its facility-based focus, it would be difficult to replicate statewide especially in rural areas. WMIP provides primary care case management, but state monitoring reports indicate that they have not effectively developed an integrated

care management model that involves behavioral health, chemical dependency and long term care.

State staff do see roles for the Area Agencies on Aging in integrated care. While

existing AAA case management programs could be providers in the new integrated system, more emphasis will have to be placed on chronic care management and targeting a broader client population. AAAs are possible contractors for case

management but would probably be required to follow the Managed Care Organization’s program policies rather than standards and policies developed by the

state. Managers acknowledged that there is a danger of a “medical bias” if health plans become the designated Accountable/Managed Care Organizations.

The Aging and Disability Services Administration’s vision of the components of a successful managed care organization include the following:

Incorporate a health home which will include primary care that will be comprised of team members - the team membership will be tailored to the individual needs of the client,

Incorporate choice and independence as a part of care planning, Involve a “secondary health home” which will address client needs related to

issues such as housing, transportation, family support, self-management, etc. When asked about Regional Health Authorities (RHAs), state managers viewed

RHAs as possible planning and coordinating entities that could bring local communities together to work on a geographic region’s public accountability, a

regional plan, create a safety net for high risk clients and engage consumers, local governments, non-profits in the further development of the local system. The state would develop the principles that guide the designation of RHAs, but RHAs would

not be a pass-through for state and federal funds and would not contract for services.



State staff agreed that there is a mandated stakeholder process that should involve consumer organizations like AARP, Area Agencies on Aging, acute care and chronic

care providers, local government and consumers.

Stakeholder involvement will be concentrated in the following areas; The legislative report required in HB 1738, The CMS planning grant,

Implementation of elements of the Affordable Care Act especially related to chronic care management,

Healthy Options, Health Innovation for Washington.

Responsibility for these activities will be with the Health Care Authority (HCA). HCA’s primary focus is on coordinating care to save money in Medicare/Medicaid.

The Governor wants to limit the inflation growth rate to 4% which is predicted to save $26 billion dollars in ten years. HCA management sees the CMS Dual Eligible Planning Grant as an opportunity to study this in detail to:

Determine how the money gets spent, Identify the state’s share of Medicare savings and who else gets a share,

Identify the Accountable Care Organization (s) (current MCOs may not be able to perform at the level the state needs),

Determine what to measure (metrics, assessment – e.g., Massachusetts Blue Shield/Blue Cross Contract for quality control content has 32 measures.)

Views of Washington Health Plans/Providers

The state of Washington has seven health care plans listed on the website currently

serving Healthy Options clients (mainly moms and kids). They are Asuris Northwest Health, Columbia United Providers, Community Health Plan, Group Health, Molina, Regence and Kaiser Permanente.

Community Health Plan of Washington (CHPW) has expressed interest in additional

collaborative efforts including integrating case management activities across all service systems, teaming long-term care case managers with other case management disciplines to address reoccurring care management issues for

consumers, integrating financing through a managed health plan, integrating/sharing consumer data and information to better manage care,

connecting quality to reimbursement for performance. CHPW sees the need to contain health care costs and the importance of finding

solutions to unnecessary hospitalizations, especially related to jail and homeless populations. Early contact with hospitalized clients will be essential and the system

needs to follow the client after discharge to assure appropriate and successful transitions. High risk clients need to be identified in order to provide the right care

at the right time.



CHPW’s vision of the key components of an integrated care system includes: 1. A health provider home that includes a multi-disciplinary care team focusing on

evidence-based treatment,

2. a wide range of providers,

3. a focus on self-management,

4. a rate setting and resource allocation process that is reasonable and responsive

to stakeholder experience and input.

CHPW sees the AAAs as a logical provider for case management of the aging and

adult population in need of long term supports and services. CHPW believes that ongoing stakeholder involvement in the next steps of the state’s CMS Dual Eligible

Planning Grant will be critical in achieving a workable integrated model. They recommend that health care plans, Area Agencies on Aging, health, behavioral health, and long term care providers all be involved in the process. While the state

will be setting the agenda, the model should not be a foregone conclusion.

There are only 2 integrated care models operating in the state – through Molina and PACE. The Washington Medicaid Integration Partnership (WMIP) is managed care for SSI or SSI-related Medicaid adults in Snohomish County. Molina is the health

plan for this pilot project, and medical, mental health, chemical dependency treatment services, and long-term care services are all part of the managed care

benefits. Molina’s staff were not available for an interview. State monitoring reports indicate that Molina only partially met the long-term care expectations of the

contract. A 2010 research report done by the Research and Data Analysis Division of DSHS indicates that the project has not demonstrated cost savings at the county level -this may be because those who are most likely to benefit from integrated

care have been more likely to dis-enroll. The project is not serving clients with as high of acuity as the department expected. The mortality rates and inpatient

hospital admissions are somewhat lower for those in WMIP. There has been an increase in chemical dependency treatment but it is lower for WMIP enrollees compared to peers not in WMIP (not statistically significant).

PACE, a totally integrated health and long-term care model serving people over age

55 in a designated service area in King County, has been successful and has a very small percentage of its population in the nursing home compared to the general population of comparable age. The model is difficult to replicate because of reserve

requirements and the facility-based nature of the (adult day center) program. It is seen as more appropriate for urban areas, and across the nation, there has not

been much growth in the program. They do include components that should be replicated in the future model for integrated care: acuity assessment, interdisciplinary staffings, home and community-based provider training specific to

the client, involvement of home and community-based providers in implementing care plans to achieve positive health outcomes and support for home and

community-based providers from the team.



A Survey of the Current Landscape for Integrated Care: Results of Research on National and State Trends

Washington State Innovations: AAA Models for Integrated Care

Four demonstrations/innovations in the state that improve the healthcare system

and serve as models for integrated care are managed locally by Area Agencies on Aging. These models warrant serious consideration in the design of integrated care.

Care Transitions

Studies across the country demonstrate that potential gaps in communication and coordination when patients transition from one care setting to another can result in

higher patient risk, increased costs and rehospitalization. CMS has placed emphasis on improving this process through “Partnership for Patients: Better Care, Lower

Costs” with two goals: 1) Keep hospital patients from getting injured or sicker and 2) Help patients heal without complication, reducing hospital readmissions by

20 percent compared to 2010.

To implement this CMS Affordable Care Act initiative, $500 million in funding has been made available to community-based organizations partnering with hospitals to help patients safely transition between settings of care.

In August 2010, the Northwest Regional Council (NWRC) (the Area Agency on Aging

that serves Island, San Juan, Skagit and Whatcom Counties), implemented the Care Transitions Intervention (CTI) coaching model for dual eligible clients in Whatcom County who also received case management and in-home services. The

contract is with Qualis.

The program assigns a transition coach to work with patients with complex care needs and family caregivers to learn self-management skills .The coaching staff

provide one hospital visit prior to discharge, one home visit and 3 follow-up phone calls over a 4 week period to dual eligible clients residing in Whatcom County. The client interventions are focused on 4 areas: 1) medication self-management, 2)

timely primary care/specialty care follow-up, 3) use of a patient-centered record (personal health record), and 4) identification of red flags that indicate a worsening

condition. The NWRC case management unit receives an automatic daily report of hospitalized

clients from St. Joseph’s Hospital. NWRC coordinates with the Qualis Care Transitions Specialist to confirm program eligibility. Sixteen NWRC employees were

trained in coaching techniques and additional workshops have been provided to focus on intervention techniques. Currently four case managers are assigned to provide coaching including nurses and social workers.



Recently NWRC received funding from ADSA to include CTI as a core service of its Aging and Disability Resource Connection pilot. The Transitions Program supports

coaching for any hospitalized patients, 18 and older, regardless of insurance. It is planned to expand to Skagit County in 2011.

ADSA Chronic Care Management Projects

The Chronic Care Management projects developed by ADSA in partnership with the Health Care Authority and the Area Agencies on Aging were designed to improve

the health of enrollees by providing evidence-based assessment and interventions, coordination of health care and supportive services, education and training in improving self-management skills and improving functional and self-care abilities to

slow progression of disease or disability. The state recognized that five percent of Washington’s Medicaid clients account for 50 percent of the costs. They are

consumers of long term care who often have a diagnosis of depression and chronic pain. Since the current health care system is focused on acute care, it does not manage chronic conditions.

Five Area Agencies on Aging (Northwest, Olympic, Yakima/Southeast, Pierce, and

Eastern WA) contract with the state to perform chronic care management for selected home care clients. A Predictive Modeling (PRISM) system identifies

participants who have high medical cost and risk determinants. The system identifies high risk clients by looking at the past twelve months of medical claims; diabetes, cardiovascular disease, mental health and substance abuse; pharmacy,

inpatient care, and emergency room utilization, risk score in top 20%. Data from the Comprehensive Assessment Resource Evaluation (CARE) tool adds LTC risk

criteria. The incidence of at least one of the following criteria is considered: lives alone, high risk moods/behaviors, health self-rating is fair or poor, overall self-sufficiency declined in last 90 days, greater than six medications.

The Chronic Care Management intervention design employs a nurse case manager

with a client ratio of 45 to 1, in order to provide face-to-face visits as well as telephone support. Evidence-based protocols are used to address diabetes management, pain management, fall assessment and prevention planning,

medication management, health action planning, and coaching for activation. The assessment includes the PAM, Patient Activation Measure. Nurses work with the

client to develop a client-centered Health Action Plan and goal setting worksheet. These goals are set with the client according to activation level and education is provided for self-management of chronic illness. The client is in charge of the care

plan and sets the pace for change based on perception of need and readiness for change.

In the second year of the evaluation, Chronic Care Management enrollees were less likely to have inpatient hospital stays involving emergency room activity, nursing

facility costs were lower, in-home care costs higher. The program saved $27 per month per client enrolled, this included medical cost savings, increased long-term

care costs, and the cost of the nurse intervention.



Nurse case manager file reviews showed that about half of the clients in the sample achieved improvement in health condition, living environment or access to

treatment. The HEDIS survey results, for all five of the areas of health measured, pointed to better self-reported health outcomes in the treatment group in overall

health rating, patient activation measure, overall self-sufficiency, pain impact and quality of life scale.

King County Care Partners—Rethinking Care

This project, developed by the Health Care Authority, contracted with Seattle-King County Aging and Disability Services (AAA) to provide chronic care management for SSI recipients with a King County residence, at least one chronic condition, and at

risk for future high medical expenses and mental illness and/or chemical dependency. A community-based RN led the multidisciplinary care management

interventions. Components of the project included collaborative goal-setting, chronic disease self-management coaching, joint visits to physician appointments, frequent in-person and telephone monitoring, connection to community resources

and care coordination across medical and mental health systems.

Fifty five percent of the clients were women with an average age of 51, and 50% had serious mental illness. Sixty two percent of those selected to participate were

given an initial assessment and 51% went on to establish at least one health care goal. The results of the primary analyses are encouraging and suggest positive impact of the program. Marginally significant findings included lower per member

per month Medicaid medical costs, lower inpatient medical costs, lower odds of inpatient medical costs, higher per member per month long term care costs, higher

opiate substitution treatment costs, lower per member per month total criminal charges, and lower per member per month, felony/gross misdemeanor charges.

Chronic Disease Self-Management Program - Replication of the Stanford School of Medicine Program

The Chronic Disease Self-Management Program is a workshop given two and half hours, once a week, for six weeks, in community settings such as senior centers,

churches, libraries and hospitals. People with different chronic health problems attend together. Workshops are facilitated by two trained leaders, one or both of

whom is a non-health professional with a chronic disease themselves. Subjects covered include: 1) techniques to deal with problems such as frustration, fatigue, pain and isolation, 2) appropriate exercise for maintaining and improving strength,

flexibility, and endurance, 3) appropriate use of medications, 4) communicating effectively with family, friends, and health professionals, 5) nutrition, and 6) how to

evaluate new treatments.

It is the process in which the program is taught that makes it effective. Classes are

highly participatory, where mutual support and success build the participants’ confidence in their ability to manage their health and maintain active and fulfilling

lives.



The original concept began when the Division of Family and Community Medicine in the School of Medicine at Stanford University received a five year research grant

from the federal Agency for Health Care Research and Policy and the State of California Tobacco-Related Diseases office. The purpose of the research was to

develop and evaluate, through a randomized controlled trial, a community-based, self-management program that assists people with chronic illness. Subjects who participated in the program, when compared to those who did not, demonstrated

significant improvements in exercise, cognitive symptom management, communication with physicians, self-reported general health, health distress,

fatigue, disability and social/role activities limitations. They also spent fewer days in the hospital and there was also a trend toward fewer outpatient visits and hospitalizations. These data yield a cost-to-savings ratio of approximately 1:4.

Many of these results persist for as long as 3 years.

The Aging and Disability Services Administration, with funding from the National Council on Aging, has supported four AAAs (Pierce, Olympic, Northwest, SE Washington) and they have developed 24 host organizations with 49 sites hosting

workshops. The workshops are offered in a variety of locations, including community centers, hospitals, physicians’ offices and in faith-based facilities. The

classes are offered in English, Spanish, Samoan, Korean, Vietnamese and Russian. In addition, 9 tribes are participating in this program. The CDSMP is also now

offered as one of the services available under the 1915(c) home and community based waiver.

Over the past several years much has been written and discussed about integrating supports and services for the dual eligible population. However there is not much

detail available about the specifics of how to operationalize integrated managed care.



Lessons from States Similarly Situated To Washington

Massachusetts

ASAPS (the term for the AAAs in that state) provide care transition services,

nursing home counseling, diversion, disease management, consumer directed care and other supports needed to keep clients living in the least restrictive setting possible. This network functions in a manner similar to the Community Health

Teams in Vermont and the network that is established in North Carolina.

Both Massachusetts and Vermont claim that a key component in health reform is the inclusion of “community care teams” as extensions to the traditional roles of physicians and hospitals. The teams partner with acute health care systems to

incorporate social and functional personal care services into the care planning and management for people with complex care needs.

Massachusetts required the medical networks to establish contractual links with “geriatric” service managers but not own them. MassHealth members age 65 and

older have the option of enrolling in a coordinated health Senior Care Options (SCO) plan. SCO is a comprehensive health plan that covers all of the services

reimbursable under Medicare and MassHealth, through a senior care organization and its network of providers. Enrollment is voluntary. There are four SCOs serving about 18,000 dual eligible seniors.

Members of a SCO have a primary care physician who is affiliated with the senior

care organization. The team includes a physician, nurses, specialists plus a “geriatric” service coordinator, who is employed by a community-based ASAP (AAA). The team works with the member to develop a plan of care. Members have

24 hour access to them.

Massachusetts state law under section 9D Chapter 118E lists what the ASAP (AAA) is responsible for, the law requires contracts with the ASAPs.

Minnesota

Integrated managed care focuses on a strong clinical model that requires a health home. The managed care entities provide case management, primary care and chronic care management across all domains.

Long-term care is included in managed care because state statute required that

level of integration. The state did not require the health plans to contract with the counties, but many did because the counties had an existing and successful case management system. There is also the belief that case management can be more

effective for consumers if it is separate from the health plan.



North Carolina Under the Community Care of North Carolina program, which has been in place since 1998, the medical home model uses local non-profit “community networks”

that are comprised of physicians and hospitals and also social service agencies and county health departments to provide and manage care. The CCNC program is

centered around these local networks of community providers. Medicaid enrollees receive care through non-profit local community networks. Each network is responsible for managing its enrollee’s care.

Because the networks are local, it is believed that they are able to reflect local and

regional needs and resources. The networks receive an “enhanced care management fee” for older enrollees and enrollees who have a disability. The networks hire local case managers, and each network also has a physician who

serves as a clinical director, and is responsible for working with a statewide board of directors to organize and direct disease and care management initiatives across

the networks. As of 2009, there were 14 community networks in North Carolina covering 913,000 Medicaid enrollees.

Case managers are members of each community network, and work in concert with physicians to identify and manage care for high cost and high risk clients. These

case managers coordinate care and services, provide disease management education, provide transitional supports, and collect and report data on process and outcome measures to assist with quality improvement efforts.

Ohio

Ohio AAAs currently contract with health plans to provide hospital and nursing facility transitions, chronic care management, health risk assessments and coaching

for self-management for the over 60 population. They also complete a statewide standardized assessment and provide ongoing care management for the 60 plus

population. They feel that their ability to perform those functions provide them a unique place in the managed care system currently in place in Ohio. The State of

Ohio is contemplating moving to a single point of mandatory care management for all clients. The Ohio AAAs are concerned that a single health plan will not be able to address the issues of rural areas. Ohio AAAs are also interested in watching the

development of recently passed legislation in Oregon.

Oregon The state of Oregon is reorganizing state government to align agencies providing

health care services into the Oregon Health Care Authority, led by Dr. Bruce Goldberg. This reorganization, passed by the legislature, becomes effective July

2011. The long-term care and developmental disabilities programs will remain in the Department of Human Services. Mental Health and Addiction Services will be moved to the Oregon Health Care Authority.



Four years ago, the state began to consider integrated care. In 2006, a report entitled “Recommendations on the Future of Long Term Care in Oregon” was

completed. The workgroup appointed to work on this report was asked to consider several questions, of which one was “What cost-effective and quality-based

combinations of acute and long-term care could Oregon develop to serve certain individuals with chronic conditions and diseases?” The report stated that fragmentation between long-term care and acute care results in 1) poor

coordination of services among providers, which leads to poor quality of care; 2) lack of accountability for overall quality of care; 3) difficulty navigating the

system and 4) high costs. The 2006 report recommended developing at least one pilot to provide integrated

and coordinated care by combining funding of Medicare, Medicaid and Medicaid long-term care services into one entity. The goal was to improve health and quality

of life while respecting choice, self-direction and dignity, build upon Oregon’s strong community-based care system and strong presence of managed acute care (OHP serves people with disabilities in managed care). The group recommended a robust

quality monitoring system to ensure a consumer-centered system. There was a strong commitment from the LTC planning subgroup for the pilot to build on local

services, including community and public partnerships. The original proposal for a pilot project was that enrollment would be voluntary and would concentrate on

serving people over age 65. After the gubernatorial election last fall, the discussion focused on including all of

the Medicare/Medicaid dollars including long-term supports and services (LTSS), developmental services and behavioral health. New entities might need to be

developed to administer the funding. Oregon submitted a dual eligibles planning grant to CMS. The grant included a goal to produce savings through effective case management and strengthened support services rather than mechanical reductions

in payment. The Governor wanted all the Medicare savings in the beginning and proposed to reduce the state’s share of savings over time.

The LTSS stakeholder process included nursing homes, area agencies on aging and managed care entities, but the process turned negative. There was common

ground around person-centered planning, personal care coaches, medical homes for high cost users. There was agreement about the value of coordinated care and

bundled payments, but concerns surfaced that health plans would not be ready to take this on and that large corporations were not trustworthy. Subsequently, the Governor decided not to include long-term service and supports.

The discussion about long-term supports and services has shifted to bringing a pilot

currently operating in Washington County to scale statewide, but no date has been set to do this. This project identifies high risk long-term care clients who are also high users of health care. Clients are: 1) in LTC, 2) in CareOregon (a managed

care organization), 3) at Virginia Garcia (a safety net clinic which is involved with primary care home venture), 4) not in a nursing home, and 5) have either a high

acuity score and will therefore likely use high cost services, or 6) uses 4 or more drug classes.



Currently in Washington County the health plan assigns a nurse practitioner and

that person works with the LTC case manager to develop a joint health and home and community-based service plan.

To expand to statewide coverage would require the OHA to include the process in its managed care contracts and for Seniors and Persons with Disabilities to include

the requirement in their contract.

Vermont The State of Vermont has recently received a planning grant from CMS to design

and implement an integrated managed care system. Vermont is interested in creating more flexibility in the services authorized and in more accountability from

their providers. Vermont intends to issue RFPs that will specify in detail what they want to

purchase, while bundling their rates. The state administrators envision that the state will be the managed care entity, assuming risk while contracting with existing

providers for the service package. The service package will include all services including assessment, authorization, service planning and services. Additionally,

Vermont will create “community health teams” comprised of a physician, possibly a nurse, therapists, etc., who will be either contracted with the managed care entity or will have a negotiated service agreement with that entity. Area Agencies on

Aging could submit a proposal to become the managed service entity but they would have to become a provider of all other services as well. Currently, the AAAs

do not operate in that fashion. Vermont feels that it will be more likely that the managed care entity will/should contract with AAAs for case management.

Vermont has a standardized assessment that is utilized by the AAAs for assessing need and eligibility for their waiver clients. There is interest in expanding the use of

the assessment, but more importantly interfacing this tool with medical records currently used by the acute care system.

Vermont is also pursuing implementing hospital transition activities.

Like Washington, Vermont has a long and successful history of local providers serving their long-term care population. They recognize the value of continuing those relationships in order to achieve the most favorable outcomes for clients.

Wisconsin

Family Care in Wisconsin is a managed long-term supports and services program serving older people, people with physical disabilities and people with

developmental disabilities who qualify for Medicaid. It currently operates in 57 of the 72 counties with 9 MCO’s (Managed Care Organizations) responsible for home

and community-based supports and nursing homes. The 9 MCO’s include 1 county



government, 4 Family Care Districts (public entity comprised of a consortia of counties), and 4 private non-profits.

Wisconsin has 3 Area Agencies on Aging in the state that contract with county aging

units to operate the Aging and Disability Resource Centers. Aging and Disability Resource Centers are the single entry point into the Family Care program. Certified screeners administer the Long-Term Care Functional Screen to assess the

individual’s level of need for services and eligibility for the Family Care benefit. If the person chooses Family Care, the resource center enrolls the person in a Manage

Care Organization (MCO). The level of need determined by the Functional Screen also triggers the monthly payment amount to the MCO for that individual.

Interdisciplinary care management includes, at a minimum, a social worker/care manager and a registered nurse. This care management is provided by the MCO,

but the person interviewed recognized that in other states it would be possible for AAA’s to provide this type of care management.

Key National Organizations and Research Studies

The Patient Protection and Affordable Care Act (ACA) requires the improvement of care management practices for persons with complex medical conditions. It strives

to change the health care delivery system by adding new investments in primary care, new resources to improve care across service delivery systems including health and long-term care, and new delivery mechanisms such as medical/health

homes. All of these efforts highlight that new care management models are needed to address the needs of high-cost populations mainly served in fee for service

models today. The goal of the establishment of the Federal Coordinated Health Care Office under

the ACA is to integrate Medicare and Medicaid benefits for dual eligibles. The solicitation for states to apply for planning grants initially provided resources for 15

states to design new structures for integration/coordination. In addition, the Community Based Care Transition federal grants recognize that continuity of care needs to be significantly improved to achieve better health care, address the total

needs of the person, and achieve savings. Significant attention on the development of new models is also designed to reduce avoidable hospitalization and

rehospitalization. Several of the states receiving the CMS planning grants have had active stakeholder involvement in helping design integrated models prior to the federal solicitation. This stakeholder involvement included more formal structures

than Washington has used such as task forces, technical advisory panels, long term care advisory committees, health system transformation teams.

The Center for Health Care Strategies has produced technical assistance briefs and

tool kits for states as they design and develop new integrated/coordinated care models. These are available on their website and are useful for those who will participate in stakeholder processes. One of the documents “From the Beneficiary



Perspective: Core Elements to Guide Integrated Care for Dual Eligibles” summarizes nine key elements, including:

comprehensive assessment to determine needs,

personalized(person-centered) plan of care, multidisciplinary care teams, family caregiver involvement,

comprehensive provider network, strong home and community-based options,

adequate consumer protections, robust data-sharing and communications system, financial incentives aligned with integrated, quality care.

These elements are seen as essential for effective integrated care programs for dual

eligible beneficiaries. Another document prepared by CHCS “Integrating Care for Dual Eligibles: an Online Toolkit” incorporates lessons learned from the CHCS Transforming Care for Dual Eligibles initiative.

Thomson-Reuters, in a qualitative study commissioned by the AARP Public Policy

Institute, reviewed care management practices in integrated care models for dual eligibles. They identified 5 key components of care management used by the plans

in their report: supportive services,

primary care, medical management,

behavioral health management, member services.

In addition, common critical themes across care management practices include:

home visits, team approach, many touches,

decentralized decision making, self-directed services,

shift in resources to primary/preventive care, a focus on transition of care, supporting care managers with information technologies,

targeted initiatives, flexible benefit packages.

The Administration on Aging’s website includes a section entitled the “Aging Network’s Role in the ACA”. AOA has sponsored webinars highlighting successful

local Area Agency on Aging projects, especially in the field of care transitions.

Staff at the national member organization for states administering Older Americans Act dollars recommended that AAAs develop realistic cost assumptions for the



product(s) they want to sell and consider a professional cost analysis. Rebranding of Area Agencies on Aging may also be necessary in developing proposals to work

with the broader populations served by health care plans.

The Center for Health Care Strategies has produced several papers in the last year on rebalancing long-term care, integrated health and long-term care programs, stakeholder processes, and toolkits for states. The authors of the reports have

reviewed several states and have identified one of Washington’s strengths as the automated, standardized assessment tool.

When CHCS visited California to review their work on implementing a duals mandatory managed health care program, they noted that they had done

considerable stakeholder work and during that process identified concerns about the readiness of health plans to serve a new population. For example, the health

plans agreed that they should develop a common health risk assessment that measures need and risk in a standardized manner in order to identify which clients need more attention. In addition, the advocates drove the development of

accessibility standards. They believe this allows consumers to have access to information about whether a particular provider or clinic is physically accessible and

near public transportation.

CHCS feels that the integrated/managed care entity should include: 1) chronic care and pain management, 2) behavioral and depression management, and 3) multidisciplinary teams. It is the perception of CHCS that local supportive services

case managers have more knowledge of ethnic and cultural issues.



A Detailed Analysis of Key Recommendations

1. Actively Participate in the Stakeholder Processes

In the current integrated care discussion, it is important for the state to organize a robust stakeholder process. This process must include significant opportunities to

develop a model that will work for Washington State by improving health and long term supports and services for the dual eligible population, including chronic care management, care transitions and a focus on home and community-based options

that produce savings. Stakeholder processes in many other states started more than two years ago. National presenters and organizations have said it can take at

least two years to develop the model and prepare the necessary waivers for integrated care. Implementation can take another year.

Area Agencies on Aging and consumers of community services should be represented in the legislative and the Department of Health and Social Services

stakeholder processes. AAA representation will ensure that attention is brought to state innovations in care transitions, chronic care management, chronic disease

self-management programs, and the provision of high performing home care case management programs. AAAs should share information with legislators and the Governor about chronic care management and its role in the development of an

effective model for integrated care.

It will be important for legislators and policy makers to understand the range of services that AAAs provide for their local communities. AAAs should begin a dialogue with their legislators about solutions to integrated care that include their

AAA case management functions and their model projects (e.g., Care Transitions with hospitals, CCM projects, Chronic Disease Self-Management).

Oregon’s Governor Kitzhaber is looking at Regional Health Authorities as part of a new organizational structure. The proposed legislation and the health care

organization that it creates at the local level should be studied closely. The Oregon legislature is currently working on a reform bill that includes a role for local

communities and the progress on this bill should be tracked. Much energy is being directed to health care purchasing, but very little dialogue has

occurred around long-term supports and services for older adults, adults with mental illness or physical disabilities and adults with developmental disabilities and

how these areas relate to purchasing discussions. AAAs should offer their expertise to the CMS Dual Eligibles Planning process and the Healthy Options Procurement, especially related to care coordination and care transitions.

The AAAs should pursue opportunities to be actively involved in the various

stakeholder processes currently underway in Washington (as described in pages 10-11).



2. Ensure Consumer Protections for Long Term Supports and Services

A number of consumer protections must be included in any new integrated health care system.

Provisions for a Comprehensive, Standardized, Independent Assessment: The state of Washington has used a statewide uniform assessment tool (CARE) to determine

level of care eligibility, specific program eligibility and to develop a service plan in conjunction with the client and the family. Besides program eligibility and service

plan development, the automated assessment provides valuable extensive data on diagnosis, treatments, cognitive functioning, and acuity levels. The data is used to authorize hours for home care and establish community residential rates. The data

in conjunction with PRISM is used to target consumers who are high utilizers of health care and who could benefit from an intensive chronic care management

intervention. Community case managers, employed or contracted through the Area Agencies on

Aging, are trained in using the assessment tool. Legislators, consumers and advocates have expressed concerns that these well-developed processes and

infrastructure for community long term supports and services not be lost in the move to integrated care.

The standardized assessment will change over time due to eligibility changes, information needs of health plans and providers, quality improvement issues, etc.

It also needs to be linked in the future to electronic health records to facilitate timely communication and effective care transition.

Provisions for Independent, Multi-disciplinary Care (Case) Management: Integrated plans that have operated for a number of years recognize that, for the populations that Washington plans to serve, both health and non-health disciplines need to be

involved in care management. Whether a plan performs care management in house or contracts for it, current models operating in the nation recognize the

provision of supportive services as a critical component of the care management framework. Common practices in care management include home visits, team approach, many touches, decentralized decision making, self-directed services, shift

in resources to primary/preventive care, focus on care transitions, supporting care managers with information technology, targeted special initiatives (e.g. behavioral

and hospital readmission issues), and flexible benefit packages.

The State of Washington has a well-developed statewide structure for supportive services and home care management provided through the Area Agencies on Aging.

AAA staff are trained to go out in the community, meet with people in their homes to do assessments and work with families. They employ a person-centered model,

have the capability to work with complex medical issues, and can identify additional community resources that can be brought to bear for a client in the development and implementation of the service plan. This is a particular strength of the current

long term care system that has helped rebalance the system. Future integration efforts should build on this network.



Assurances from the Provider Network: Consumers/advocates have expressed concern nationally about who their health and long term care providers will be in

the future and how that will affect services for them. To alleviate this concern and provide a smooth transition, some states require that managed care plans contract

with all existing Medicaid providers for a specific period of time. Florida required 12 months in their legislation, and after that year, the plan can take into account performance and quality criteria when deciding who receives a contract. Texas

required contracts with all Medicaid providers initially; now plans can contract with 80% of the network in their area. These assurances should be considered in

Washington’s move to integrated care.

3. Take Demonstrations/Pilot Projects to Scale Statewide

The full integration of health and long-term supports and services is planned for

statewide implementation in Washington by 2017. Between now and then, the state should take advantage of opportunities to improve collaboration between the health care and long term care systems that will improve health outcomes and

reduce expenditures especially for high risk clients. When full implementation occurs, these processes could be incorporated into the system to help assure

enrollees receive the right service at the right time in the right setting. Two innovative models that offer great promise for integrated care are the Care

Transitions and the Chronic Care Management Projects. Care Transitions

One of the major health care reform initiatives of U.S. Department of Health and Human Services (HHS) is the Partnership for Patients: Better Care, Lower Cost.

This initiative has two goals:

1) Keep hospital patients from getting injured or sicker: By the end of 2013, HHS wants to decrease preventable hospital-acquired conditions by 40

percent compared to 2010.

2) Help patients heal without complication: By the end of 2013, decrease

preventable complications during transition from one care setting to another, in order to reduce hospital readmissions by 20 percent compared to 2010.

To support the last goal, $500 million of funding for community-based organizations

partnering with eligible hospitals will be used to help patients safely transition between settings of care. Applications are being accepted on a rolling basis. Area

Agencies on Aging are considered a community-based organization for this purpose. The Administration on Aging recognizing the importance of this initiative sponsored a series of webinars-Affordable Care Act: Opportunities for the Aging Network.

These are available at www.aoa.gov.

New health care policies emphasize the need for effective care transitions, but the

US Department of Health and Human Services does not have a prescribed model and wants these projects as well as other aspects of the act to transform the health

http://www.aoa.gov/



care delivery system. Besides the Medicare Community-Based Care Transitions program, the health care reform law added new programs, including incentives to

reduce hospital readmissions, Medicare Independence at Home demonstrations, bonus payments for Medicare Advantage plans with care management programs,

medical home models in Medicare and Medicaid, Community Health Teams to support Medical Homes regardless of payer type, piloting bundled payments, and creating accountable care organizations.

The work being done by the Northwest Regional Council (AAA) demonstrates the effectiveness of the Care Transitions model. All AAAs should use the lessons learned

from the NWRC project to coordinate similar efforts in their local service areas.

Chronic Care Management

Six Area Agencies on Aging (5 with ADSA contracts and 1 with HCA) currently

operate chronic care management models that are serving Medicaid beneficiaries with complex chronic conditions.

This type of face-to-face chronic care management program for complex issues (as opposed to traditional telephonic programs) is being recognized nationally as necessary. These programs need to be expanded statewide as soon as possible for

Medicaid-only and dual eligible clients. This is recognized in the CMS Dual Eligible Planning Grant as Tier 1: “For high risk/high cost duals, we propose to initially focus

on expanding existing CCM models, with financing based on an innovative shared savings partnership between Medicare and Medicaid and statewide implementation

in 2012.” The state received approval of a Medicaid state plan amendment (Prepaid Ambulatory Health Plan) that provided the federal match to expand chronic care management statewide for Medicaid clients. The state is also applying for

enhanced federal match under a different Medicaid authority.

In the 2011Health Innovation for Washington proposal submitted to CMS,

development of a secondary health home model is recommended for those with severe or multiple chronic conditions, individuals with severe mental health/substance use disorders, and individuals with physical or developmental

disabilities who require expanded services beyond those required by a primary care health home. It is envisioned that these secondary health homes would use a

community health team approach to coordinate culturally competent care among multiple specialists as well as among providers of specialized community based social services including home care. AAAs could play an important role here.

Health home provisions of the Affordable Care Act state that the health home must include comprehensive care management, care coordination, health promotion,

comprehensive transitional care/follow-up, patient and family support and referral to community support. It is not required that the Health Plans directly provide all these functions and a hybrid model can be developed that includes community

contractors.



4. Build Strong Connections with the Health Care System

AAAs should publicize their ability to address hospital transitions, family caregiver support, housing and the community connections they have, especially through the

single entry points of the Aging and Disability Resource Connection. AAAs should emphasize their statewide system and infrastructure that is strength-based, as they create partnerships to find solutions with managed care providers. AAAs should not

be limited to their care management role in health care reform, but should also be considered for potential roles in quality oversight and care monitoring.

Long term supports and services, including home and community-based programs, are not included in the draft Healthy Options RFP, but care (case) management and

care transitions will be necessary for the new population to be served effectively. The relationship between the AAAs and the Federally Qualified Health Center(s) will

be important in serving the needs of individuals who receive long term supports and services. The Healthy Options providers should be motivated with capitation to reduce hospitalizations.

Since the Affordable Care Act requires that hospitals not be reimbursed for

Medicare patients that are readmitted within 30 days, this should provide an incentive for hospitals to work more effectively with providers of long-term supports

and services. Current hospital discharge planning activities are ineffective, and hospitals should be motivated to invest upfront to improve their readmission rates.

Health care providers will be interested in strategies that strengthen and formalize relationships with hospitals, accountable care organizations, Medicare special needs

plans, and Medicaid managed care organizations. This should include health care providers who also serve Medicare beneficiaries.

Health plans will tend to focus on their own systems of care management and may

or may not be looking for potential care management contractors. There also may be new contractors entering the state and it will be useful to do research on their

experience and any successful models that they have developed. With the state’s current move to managed care, letters of interest for the Healthy

Options “intent to bid” were due in September 2011. AAAs should look to build relationships with all potential bidders to focus dialogue on measures that could

save money, such as care transitions and rehospitalization issues, and to educate them on the services AAAs can provide to individuals who need long term supports and services

In the past, the legislature has been reluctant to insert itself between health care

plans and the development of their networks. While legislative mandates may be unlikely, policy makers are aware of some of the previous problems with managed care providers. Performance reports from the DSHS Research and Data Analysis

Division should receive close attention when considering the design of the new integrated care system. Through the various stakeholder processes addressing

system redesign, advocates and AAAs should bring attention to lessons learned.

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