San Diego Long Term Care Integration Project (LTCIP)

November 9, 2005LTCIP Planning Committee

San Diego County Board of Supervisors&

State Office of Long Term Care

Jean Shepard, DirectorCounty of San Diego, Health & Human Services

Agency, (HHSA)

Advisory Group:Goal: Make final decisions and

recommendations for inclusion in the plan.

Planning Committee:Goal: Guide the LTCIP planning process.

Suspended Workgroups pending need for further action/decision-making

Health Plan Partners Workgroup

Finance/DataWorkgroup

Options Workgroup

Internet• Facilitates

communication• Provides broad public

education

Pamela B. Smith, Project DirectorEvalyn Greb, Project ManagerAging & Independence Services

Lead County Agency

MH & SAWorkgroup

Explore use of the Healthy SanDiego model for potentialService delivery system for LTCIP.

Determine the financialfeasibility of the proposedLTCIP for San Diego County.

Make recommendations to Planning Committee re: inclusion of mentalhealth and substance abuse services in LTCIP.

LTCI Strategies:1) Network of Care2) Physician Strategy3) Healthy San Diego Plus Ad Hoc workgroups:Care Management, Provider NetworkDevelopment, Cultural Responsiveness

Governance-Case Management-Info/Technology-Quality Assurance-Scope of Services-Workforce Issues-Developmental Disabilities-Community Network Development

Community EducationWorkgroup

Explore use of public health education models that promote improved chronic care management for LTCIP

Long Term Care Integration Project Organizational Chart & Decision Tree

April 2005

Client Referral Patterns

Why the Interest in ALTCI?

• Unintended consumer consequences• Cost shifting in both directions• Important public financing considerations• An opportunity to do better with limited resources • Managed/Integrated Care implications• Aging of the population/Chronic Care Imperative

Journal of the American Geriatrics Society, Feb. 1997

In-HomeServices

DayHealthCare

AcuteHospital

TransitSkilledNursingFacility

MedicalSpecialty

MealsService

PrimaryCare

MRS.C.

Ideal System

Mrs. C & Care

Manager

Special Needs Plans

• Institutional Beneficiaries (In or expected reside ther >90 days; Community NHC)• Dually Eligible (subsets of duals OK)• Beneficaries with Chronic Conditions (untested to be evaluated on case by case;

e.g. disease specific, plan focuses)

Lumpers vs. Splitters!

CMS Guidance to Integrating

Medicare/Medicaid

• Models: - Buy-In Wraparound - Capitated

Wraparound - Three-Party

Integrated- Plan-Level

Integrated

• Key Considerations:- Enrollment- Operations- Benefits- Payments- Appeals - Part D

Implementation

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemResources and Policies

Community Health Care Organization

Chronic Care Model

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

A P

S D

A PS D

A P

S D

D SP A

Community Resources and Policy

Self-Manage-ment Support

Delivery System Design

Clinical Information

Systems

Develop Strategies for Each Component of the CCM

Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population

A PS D

A PS D

A PS D

D SP A

A PS D

A PS D

A PS D

D SP A

Organiz-ation of health care

Decision Support

Core Building Blocks

- Targeting Beneficiaries: Risk vs. Reward - Case Management / Care Coordination- Integrating Information - Quality Methods and Measures- Primary Care / Chronic Care Management

Bringing Medicare and MassHealth Together

Senior Care Options

What Works?

Centralized Enrollee Record 24/7 Access to Nurse Case Manager Joint CMS-state Medicare-style monitoring “Extra” benefits, i.e. vision, dental, hearing,

podiatry services to encourage enrollments Rates sufficient for start-up phase “Real” people to support automated

enrollment, screening, and reporting requirements

Exciting Outcomes

High enrollment in underserved, diverse neighborhoods (SCOs hire residents to do marketing/customer service)

Initial resistance by Aging industry slowly shifting to new AAA-SCO business

MMA transition to SNP MA-PD option as fast track to formal Medicare status

Enthusiastic, high-profile bi-partisan support within state government

Wisconsin Partnership ProgramWisconsin Partnership Program

Charting the Future for Special Charting the Future for Special Needs Plans: Needs Plans:

2005 Leadership Forum2005 Leadership ForumFairfax, VirginiaFairfax, Virginia

Nancy CrawfordNancy Crawford

November 2005November 2005

OutcomesOutcomes

OutcomesOutcomes

Results of Provider Results of Provider Satisfaction SurveySatisfaction Survey

64.1%

91.3%

81.5%

55.7%

7.0% 10.9%

3.4% 2.7%

41.6%

5.4%7.6%

28.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Satisfied AppropriateReimbursement

Satisfied AmountPaperwork

Satisfied Amount PhoneWork

Access to Out-of-NetworkProviders

Almost Always & Usually Sometimes & Rarely No Opinion

Medi-Cal Redesign Revisited

• Mandatory Medi-Cal Managed Care for Aged, Blind, and Disabled (ABDs) clients in all current managed care counties

• Implement Acute and LTC Integration Projects in Contra Costa, Orange, and San Diego to test innovative approached for enabling more individuals to receive care in setting that maximize community integration.

San Diego Stakeholder LTCIP Vision for Elderly & Disabled

• Develop “system” that:– provides continuum of health, social and

support services that “wrap around consumer” w/prevention & early intervention focus

– pools associated (categorical) funding– is consumer driven and responsive– expands access to/options for care– Utilizes existing providers

Stakeholder Vision (continued)

– Fairly compensates all providers w/rate structure developed locally

– Engages MD as pivotal team member– Decreases fragmentation/duplication w/single

point of entry, single plan of care– Improves quality & is budget neutral– Implements Olmstead Decision locally– Maximizes federal and state funding

ALTCI Building Blocks• Stakeholder Process• Community Education and Outreach• Care Coordination Improvement• Community Network Development• Community & Cultural Responsiveness• Personal Care Workforce Support• Integrated IT Development • Primary Care Teams/Physician support• Quality Monitoring and Measurement

Health San Diego Plus

• MediCal Aged, Blind, and Disabled offered voluntary enrollment in LTC Integrated Plan

• Models of care integrated across the health, social, and supportive services continuum:– Private entity to contract with State through RFP with

stakeholder support– Healthy San Diego Health Plus Plans to develop

program details with consultant resources

Community Feedback on Stakeholder Recommendations

• Provider Network

• Care Management

• Community & Cultural Responsiveness

Provider Network Development/ Member Service

Recommendations

– Add geriatric, disability, social service expertise– Define minimum access standards for health and

social services, including personal care services– Define minimum standards for member

services/training of providers across the continuum to meet the individual health and social service needs of aged and disabled members

• Consultants: Scotti Kluess, Carol Zernial

Care Management Recommendations

– Finalize CM model, based on previous work and stakeholder input

– Develop standards and performance measures with State, County & stakeholders for the RFSQ

– Identify CM tools, such as assessment instrument and care plan format

– Identify source and develop community-wide plan for comprehensive training/certification?

• Staff: Brenda Schmitthenner

Community & Cultural Responsiveness

– Recommend plan to involve consumers/ caregivers in decision-making for self-direction, standards for new system of care

– Identify issues of diversity (cultural, physical, cognitive+) in re: access, outreach, education

– Develop minimum requirements and performance measures w/State, County, stakeholders

–  Recommend HSD+ training plan and materials to be translated into threshold languages

• Workgroup Facilitator: Jong Won Min, PH.D.