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LTSS Integration in Health Plans and Health Systems Long-Term Quality Alliance Annual Meeting September 19, 2014
LTSS Integration in Health Plans and Health Systems Long-Term Quality Alliance Annual Meeting September 19, 2014
UnitedHealthcare’s Experience
• UnitedHealthcare Community & State serves more than 4 million members in Medicaid and Medicare programs
• We have responsibility for MLTSS in half of our states
– Nearly all have integrated approaches to LTSS
2 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Integrating LTSS in managed models
• Integrating social and functional services that are at the core of LTSS is fundamental to a managed approach to LTSS
• The most effective models integrate comprehensive benefit design
• An ability to leverage benefit flexibility is vital to an integrated model
3 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
Health plans don’t have to do it all
4 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
AAAs
CILs
ACOs
HHs Community resources should
be leveraged to maximize resources and expertise
The key is to not replace fragmentation with more
fragmentation
Our role as the integrator
• The health plan has a key role in establishing the foundation to ensure integration
• Health plans should fill in gaps, remove barriers, and support system transformation without unnecessarily replacing services provided by experienced organizations
• Relationships between entities should be unique and leverage the strengths of each organization
• Program payment – including downstream payments – should ensure adequate funding to fuel innovation while aligning incentives to improve member experience and outcomes
5 Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.
AETNA MEDICAID LTSS Integra2on in Health Plans and Health Systems
Aetna Inc. AETNA MEDICAID 7 7
Fragmented Expenditures for LTSS $192 Billion
Aetna Inc. AETNA MEDICAID 8
Aetna’s LTSS Integrated Care Goal
De fragmen1ze care whenever possible Include management and support across the care
con1nuum • LTSS
• HCBS → in-‐home or alterna1ve residen1al facility • Nursing Facility (NF)
• Medical • Behavioral
• Coordina1on of non-‐covered services and supports
Aetna Inc. AETNA MEDICAID 9
Integrated Care Strategy: Person Centered Care
Individualized case manager Face-‐to-‐face assessment -‐ Bio-‐psychosocial needs
-‐ Personal preferences -‐ Iden1fica1on of supports -‐ Condi1on specific assessment as needed
Develop collabora1ve goals to support
-‐ member needs -‐ personal preferences -‐ care provided by family/others (unpaid care)
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Aetna Inc. AETNA MEDICAID 10
Integrated, holis1c approach Support member in the least restric1ve environment Early interven1on early when changes occur Facilitate effec1ve transi1ons between systems of care Engage members early, recognizing strengths, capaci1es while
addressing cri1cal physical, behavioral, environmental and social needs
Employ evidence based prac1ces to create op1mal outcomes for members
Provide access to a con1nuum of care, based on complexi1es of individual member needs
Support, not supplant informal supports (self directed care)
Guiding Principles for Person Centered Integrated Care
Aetna’s Integrated Person Centered Care Model
Case
LTSS and Behavioral Health
Networks Non-‐covered Community Resources
Pharmacy
Grievances & Appeals
Network and Provider Services
Transi2on & Diversion Programs
Quality Management
Medical Networks
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Member / Families & Caregivers
Case Manager
Local
Aetna Inc. AETNA MEDICAID 12 12
Opportuni2es to Mi2gate Challenges • Early interven1on for change in condi1on/circumstances
• Member driven integrated care teams
• Person centered plan of care
• Back up/con1ngency plans
• Risk mi1ga1on agreements
• Cost effec1veness studies
Aetna Inc. AETNA MEDICAID 13
Barriers to ACO-‐LTSS Integra1on
Terrence A. O’Malley, MD Massachuse\s General Hospital Partners HealthCare System, Inc.
What we have here… Is a failure to Communicate
• PHS is not ready to listen to LTSS • Focused instead on learning to be an ACO
– Governance – IT integra1on – Primary Care infrastructure – Management of High Risk pa1ents
• Not sure LTSS have anything to say – No compelling data on the “value” of LTSS – No quan1ta1ve impact on readmissions, VBP – Most LTSS providers don’t know the cost of services
ACO pa1ents who need LTSS • Individuals with complex medical, behavioral, func1onal
and social needs • High cost/High Risk: Duals, Medicare >6 chronic condi1ons,
Chronically mentally ill • Receive care from mul1ple providers, in mul1ple sites
across prolonged episodes of care • Require a\en1on to transi1ons of care, longitudinal
coordina1on of care, medica1on management and referral management
• Share a common pa\ern: High admission rates, High ER use, High LTPAC use, High impact of the social determinants of health such as housing, transporta1on, home based supports.
Building a common IT plagorm
• IT integra1on of LTSS with the rest of health care providers requires five components: – An electronic highway that connects all par1es – Low cost access ramps to the highway for those without EHRs and millions to spend
– Trucks to carry the informa1on reliably between sites – Cargo to put in the trucks, ie informa1on, that is valuable to the sites and standardized so it can be used everywhere
– A compelling business case for this exchange
Puhng the Pieces Together • Highways: HIE build-‐out con1nues across the country • On and Off Ramps: free, open source, Java based sojware
which allows non-‐EHR users to send and receive standardized messages
• New trucks: Consolidated CDA, the required health care data exchange standard s1pulated in MU 2. A significant improvement in flexibility
• High value cargo: standardized demographics, func1onal status, cogni1ve status, nutri1onal needs, treatment plans, medica1on lists, care plans
• The business cases: what does LTSS know that ACO providers need to know? What do ACO providers know that LTSS needs?
