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Strategies to Improve Care Management for Beneficiaries with Complex Needs

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Strategies to Improve Care Management for Beneficiaries with Complex Needs. Managing the Care and Costs of High-Cost Beneficiaries in Medi-Cal Fee-for-Service June 9, 2009 Alice Lind Associate Vice President Center for Health Care Strategies. CHCS Mission. - PowerPoint PPT Presentation
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Strategies to Improve Care Management for Beneficiaries with Complex Needs Managing the Care and Costs of High- Cost Beneficiaries in Medi-Cal Fee- for-Service June 9, 2009 Alice Lind Associate Vice President Center for Health Care Strategies
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Page 1: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Strategies to Improve Care Management for Beneficiaries

with Complex NeedsManaging the Care and Costs of High-Cost Beneficiaries in Medi-Cal Fee-for-Service

June 9, 2009

Alice LindAssociate Vice President

Center for Health Care Strategies

Page 2: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

CHCS MissionTo improve health care quality for low-income children and adults, people with chronic illnesses and disabilities, frail elders, and racially and ethnically diverse populations experiencing disparities in care.

►Our Priorities Advancing Health Care Quality and Cost Effectiveness Reducing Racial and Ethnic Disparities Integrating Care for People with Complex and Special Needs

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Page 3: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Managing Care in Medicaid

Goals:► Improve or maintain health status

► Create accountable medical homes

► Coordinate care for those with complex conditions

► Control cost

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Page 4: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Purchasing Strategies Used by StatesInterviews with Medicaid officials in 12 states to examine innovations in care management for the SSI/ABD population.

Key Themes:1. Growing momentum to move beyond FFS to more coordinated

approaches (e.g., EPCCM, medical home).2. Increasing interest in alternative financing methods (e.g.,

shared risk/savings, P4P, etc.). 3. Emerging efforts to develop and test more appropriate

performance measurement and monitoring strategies.

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Page 5: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Common Elements: Emerging Models of Care• Identifying and stratifying target populations• Targeting tailored interventions• Integrating/coordinating services (e.g., physical &

mental health)• Creating better connections between patients and

providers• Using appropriate measures to promote

accountability• Structuring financing to support care management

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Page 6: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Key Issues: Emerging Models of Care• Predictive Modeling• Health Risk Assessments• Physical-Behavioral Health Integration• Role of Medical Homes• Engagement Strategies (Patients and Providers)• Accountability

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Page 7: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Elements of Medical Home

• A participant is linked with a physician, non-physician medical practitioner, clinic, or other safety net provider who will serve as their medical home.

• The medical home acts as a team to:1. Assess the participant’s health care needs 2. Coordinate and plan the participant’s care 3. Provide quality primary care services and preventive screenings4. Authorize referrals to specialists, and5. Provide linkages to other care and equipment providers

• The team has a whole person orientation: “Success depends on their ability to focus on the needs of a patient or family one case at a time.”

• The medical home integrates IT to support quality and safety.

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Page 8: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Typical Medical Home Enhancements

• Beneficiaries are offered:► Toll-free health advice, 24/7;► In person health education and counseling;► Linkages to community-based services (housing, behavioral

health, etc.);► Integrated care management for those identified as having

complex medical and social needs.• Providers are offered:

► Practice support as needed;► Training and education on Patient-Centered Medical Home;► Technical assistance on quality improvement, evidence-based

medicine, IT resources.

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Page 9: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Medical Home – current literature• Evidence indicates that medical homes improves health outcomes

and reduce access disparities. 1

• Physician-based organizations support the medical home because it provides an on-going relationship with the patient that improves quality.2

• National Demonstration on Patient-Centered Medical Home3:► Transformation requires a strategic developmental approach.► Cautious optimism despite the challenges of implementation.

• Complex care management in Medicare demos4:► Programs that reduced hospital costs for Medicare beneficiaries with multiple chronic

conditions who were generally not cognitively impaired included key features (next slide).1 Rosenthal TC. The Medical Home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008; 21(5): 427-440.2 Joint Principles of the Patient-Centered Medical Home, March 2007; American Academy of Family Physicians, American Academy of Pediatrics, American

College of Physicians, and the American Osteopathic Association. 3 Nutting et al. “Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home”, Annals of Family

Medicine, 2009.4 Brown R et al. The Promise of Care Coordination. Located at http://socialworkleadership.org/nsw/Brown_Full_Report.pdf

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Page 10: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Care Coordination in Enhanced PCCM Programs• Care coordination in PCCM programs has some of these characteristics,

but not all (upcoming article by Verdier):► Targeting of patients at substantial but not extremely high risk of hospitalization (OK,

PA, IN)► In person contact with patients (some in OK, PA, NC, and IN, but most is by

telephone)► Close interaction between care coordinators and physicians (best in NC, more limited

in other states)► Access to timely information on hospital and ER admissions (generally lacking in all

states)► Medical education and social services to patients, including education on self-

management of care, especially medications (some in all states but AR)

• In considering lessons from Medicare, keep in mind differences between Medicare and Medicaid beneficiaries

► Medicaid ABD PCCM beneficiaries generally are younger, have lower education and income levels, fewer family and community supports, more mental health and substance abuse problems, and more housing problems

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Page 11: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Proposed Medi-Cal Model:Enhanced Medical Home (EMH)

• Starting with high level concept:► Target population: 360,000 high cost Medi-Cal Fee-

for-Service enrollees ► CA will contract with one or more entities to

administer Enhanced Medical Home model► Best practices from other states will be integrated ► Mandatory statewide: where managed care is

available individuals can select the Medical Home model or a managed care model.

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Page 12: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Model Option 1: State-operated

• Oklahoma’s Sooner Care Choice:► Builds on, supports, and strengthens the existing

primary care provider network► Provides supports to beneficiaries and providers

(nurse advice; education)► Provides care coordination to high risk beneficiaries► P4P model rewards providers► Difference for CA: OK pays Medicare rates to

providers; fully capitated managed care was not viable

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Page 13: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Model Option 2: Single Private Vendor• State of Illinois:

► Single contractor provides all operations► Vendor forms and operates provider network► Vendor provides supports for beneficiaries and

providers► Care coordination through subcontracted

arrangement for high risk population► Is relatively quick to implement & can be contracted at

risk► Difference for CA: local involvement not a priority in

IL, except for Disease Management

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Page 14: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Model Option 3: Local Public/Private Partnership• Community Care of North Carolina:

► Gradually developed local public/private entities in 14 geographic locations

► Local entities responsible for network, provider and beneficiary supports

► Local determination of QI efforts► State funds are split between providers and regional

partnerships► Difference for CA: NC had many years to develop

model before cost neutrality was required

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Page 15: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Model Option 4: Blended Model

• Washington’s King County Care Partners:► Local entities given preference if willing and able to

contract for enhanced medical home► Statewide contract awarded to cover remaining

geographical regions► Statewide vendor’s role diminished over time, shifting

responsibility to local and state staff as they developed capacity

► Difference for CA: WA grew out of totally unmanaged care for ABD population; cost neutrality a goal but not required

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Page 16: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Your Role in the Medi-Cal Project

• You are a key informant!• Respond by June 10 (tomorrow) with your

availability to interview on June 22, 23, or 24• CHCS will reply with your time & directions by

June 15• Optional: Review documents on CHCS or CHCF

website from December 15 meeting• Email with questions: [email protected]

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Page 17: Strategies to Improve Care Management for Beneficiaries   with Complex Needs

Visit CHCS.org to…

• Download practical resources to improve the quality and efficiency of Medicaid services.

• Subscribe to CHCS eMail Updates to find out about new CHCS programs and resources.

• Learn about cutting-edge state/health plan efforts to improve care for Medicaid’s highest-risk, highest-cost members.

www.chcs.org

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