Optum WA Health Home Program. City of Tacoma - MHSUD Collaboration June 2015 Bea Dixon, BSN, PhD on behalf of the entire Health Home Team
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1 Optum WA Health Home Program City of Tacoma - MHSUD Collaboration June 2015 Bea Dixon, BSN, PhD on behalf of the entire Health Home Team
2 Health Home Program: it s about people Hearth Failure NOS with hypertension with atrial flutter Schizophrenia Diabetes juvenile onset Chronic pancreatitis Bipolar disorder Bruce, 37 PTSD Antisocial personality disorder Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2
3 What if. Fragmented Care: Conflicting diagnoses Conflicting advice Duplicated and unnecessary services Delays and other mishaps Major irritant Care Coordination Fragmentation Care Coordination: Providers work together Comprehensive, coherent and continuous response to the person s needs Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3
4 Health Home Program: it s about people Spina Bifida moderate Pressure ulcers, ankles and legs Depression Psychotic disorder NOS Bipolar disorder Attention deficit with hyperactivity Alcohol dependence Rick, 17 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4
5 What if. Medical Model Focus on diagnosis Focus on treatment Focus on what is wrong Care Coordination Fragmentation Person-Centered Focus on Rick Focus on his goals Focus on what is strong Capitalizing on his abilities Connecting Rick with a Wellness Coach Person- Centered a purely Medical Model Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5
6 Health Home Program: it s about people Vascular disease Chronic liver disease Thyroid disorder Depressive disorder Psychosis NOS Amphetamine dependence Charmaine, 64 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6
7 What if. Integration: Care Coordination Fragmentation - A whole person orientation - One single funding stream for MH/CD/Medical services - One entity assuming full accountability Person- Centered purely Medical Model Integration silos Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7
8 What if. Care Coordination Fragmentation Community Leadership Person- Centered purely Medical Model Integration silo-ed Imagine Pierce County Local innovation Local priorities Reduce duplication Develop our own workforce What else? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8
9 Health Home: Qualified Health Home Lead Entities OPTUM WA LEAD ENTITY Section 2703 of the 2010 Affordable Care Act Broad-based regional provider networks Contracted to the State as a Qualified Health Home Subcontract with local/regional organizations that provide all Health Home coordination services HIGH COST / HIGH RISK POPULATIONS Medicaid Managed Care Amerigroup and Molina Medicare/ Medicaid-Fee for Service (Duals) Medicaid-Fee for Service 20 CARE COORDINATION ORGANIZATIONS COVERING 4 AREAS In WA 100STAFF Currently 18,500 people referred to Optum Lead Entity SERVICE DELIVERY SYSTEMS Primary Care Mental Health Chemical Dependency Hospitals Long Term Care Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9
10 Optum Network: 20 Care Coordination Organizations Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10
11 HEALTH HOME: Beneficiaries HIGH COST / HIGH RISK POPULATIONS Medicaid Managed Care Medicaid enrollees with complex conditions and high service needs who are at significant risk for health issues and have a PRISM score of 1.5 or higher (Predictive Risk Intelligence System). The PRISM score of 1.5 means a person s future medical expenditures are expected to be 50% greater than the base reference group, the WA SSI disabled population. Medicare/ Medicaid-Fee for Service (DUALs) Medicaid-Fee for Service Example Jane has been diagnosed with congestive heart failure (9.4%), poorly controlled type 1 diabetes (6.0%), and chronic obstructive asthma (5.3%). She was hospitalized once in the prior days (5.8%), and twice in the prior days (2 x 2.1% = 4.2%). She has been to the Emergency Department twice in the past month without being admitted to the hospital (2 x 1.7% = 3.4%). Her risk of an inpatient admission in the next 12 months is 28.3%. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11
12 County Duals Non-Duals Total County Duals Non-Duals Total Clallam Adams Grays Harbor Chelan Jefferson Douglas Kitsap Ferry Lewis Grant Mason Lincoln Pacific Okanogan Thurston Pend Oreille Island Spokane San Juan Stevens Skagit Whitman Snohomish Yakima King Asotin Pierce Benton Clark Columbia Cowlitz Franklin Klickitat Garfield Skamania Kittitas Wahkiakum Walla Walla Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12
13 Health Home: program goals 1. Improve participants health outcomes by: - Mobilizing and coordinating primary care, specialist, behavioral health, chemical dependence, long-term care services and supports - Increasing participants engagement levels and selfmanagement skills 2. Reduce preventable hospital admissions and re-admissions 3. Reduce avoidable emergency room use Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13
14 Health Home: a fiercely person-centered approach What do I need to know about you as a person? Listening vs Telling What is most important to you right now? What s your first step to get to your dream? What s your dream? Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14
15 Health Home: a whole person orientation Medical Social Supports Mental Health Longterm Care Chemical Dependency Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 15
16 Health Home: a deliberate marshalling of care activities and resources Comprehensive Care Management Care Coordination and Health Promotion Individual and Family Support Transitional Care Referral to Community and Social Support Services Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 16
17 Health Home: a deliberate organization of care activities between providers Cross System Collaboration Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 17
18 LEAD ENTITY ACUTE CARE Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 18
19 About the goals 1. Reduce preventable hospital admissions and re-admissions 2. Reduce avoidable emergency room use 18 Nr of ED visits April 2015 Average: 4 visits/month A B C D E F G H I J K L M N O Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 19
20 NOTIFICATION SYSTEM PreManage TM (by Collective Medical Technology) Optum: Care Manager CareManager CMT Care Coordination Organization Health Home Beneficiaries Care Coordinator Other Transmitted Information Patient Health Information Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 20
21 Heath Home : a great balcony view Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 21
22 We see We practice We look forward Integration Care Coordination Fragmentation - A whole person orientation - Person-centered approach - One single funding stream for MH/CD/Medical services - One entity is assuming full accountability Person- Centered purely Medical Model Integration Silos Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 22
23 We see We practice We look forward Care Coordination Fragmentation Community Leadership Person- Centered purely Medical Model Integration silo-ed Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 23
24 on behalf of the entire Health Home Team
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