Changes in the Healthcare Delivery for Seniors and Persons with Disabilities

Transcription

1 Changes in the Healthcare Delivery for Seniors and Persons with Disabilities Provider Training July 28, 2011 Lisa Hayes Manager, Senior and Disability Services Molina Healthcare

2 Introduction I Waiver and Movement of Seniors and People with Disabilities into Managed Care What stays the same? What changes? II. Profile of Seniors and People with Disabilities Healthcare Disparities Barriers to Accessing Care III. Molina s Bridge2Access Program IV. Coordinating Accommodations What YOU can do in your office What the HEALTH PLAN can do 2

3 I Waiver and Movement of Seniors and People with Disabilities into Managed Care Phased-in enrollment will be over a 12-month period, started June 1, 2011; and will continue based on beneficiary birth date Example: Beneficiaries with May(2011) birth date enrolled into Managed Care Plan on June 1, If Beneficiaries don t choose a health plan, the Department of Healthcare Services will choose one for them. 3

4 What Stays the Same Enrollment Process Beneficiaries choose a health plan Default enrollment by Health Care Options (HCO)when a plan isn t chosen Default assignment when a plan and PCP isn t chosen Beneficiaries choose a PCP All materials are available in threshold languages Health plans materials available at HCO presentations Benefits and Covered Services SPD beneficiaries receive the same Medi-Cal benefits and services as other members SPD beneficiaries have no-cost Medi-Cal coverage only They receive the same Medi-Cal ID card They use the same provider directories and online search tool as our other Medi- Cal managed care members Medi-Cal phone numbers for each health plan remain the same 4 4

5 What s Different? Enrollment Process State s outreach program works to ensure beneficiaries understand the transition to managed care and the choices available: County-specific presentations Notification letter; follow-up phone call Enrollment packet; follow-up phone call after 30 days 5 5

6 New State Requirements Stratification: All new SPD Members High Risk: Health Risk Assessment done in 45 days Requires a Care Plan Low Risk: Health Risk Assessment done in 105 days Care Plan is Optional Providers are still responsible for performing a Well Visit Assessment (e.g.iha) following Medi-Cal standards Expanded Facility Site Review Disability / Sensitivity Training Network Adequacy Requirements Dedicated Regional Center Liaison 6

7 New State Requirements (Continued) Continuity of Care Expanded Definition Members must request to stay with long standing provider Provider must accept Medi-Cal FFS rate or contracted rate whichever is greater Requests for exemptions must be made through Healthcare Options 7

8 Projected Medi-Cal FFS Enrollees: Sacramento 28,000 Estimated MonthlyTotal of FFS enrollees Sacramento 2,300 Molina Forecasted Vs. Actual Enrollment: June 2011 Forecasted vs. Actual July 2011 Forecasted vs. Actual

9 Who will be Mandatorily Enrolled in Managed Care? Medi-Cal-only SPDs with a qualifying AID Code Who is Not Eligible? Individuals with share of cost Long Term Care beneficiaries Who is Still Voluntary? Dual eligibles (Medi-Medi) Foster children Individuals with other coverage (private insurance) California Children s Services (CCS) eligible beneficiaries Pending CCS pilot projects Intermediate Care Facility (ICF) residents Top 6 AID Codes with Description 60 Disabled - SSI/SSP-Cash 14 Aid to the Aged - Medically Needy 64 Disabled - Medically Needy 6H Disabled - FPL Program 10 Aid to the Aged - SSI/SSP 20 Blind - SSI/SSP-Cash Also: 6V, 6E, 1H, 6N, 24, 6J, 6C, 2E, 6G, 1E, 66, 36, 6A, 16 (very few beneficiaries in these aid codes) 9

10 Sacramento: Geographic Managed Care Current Health Plan Options: Molina Healthcare Anthem Blue Cross Health Net Kaiser * 10

11 II. Profile of Seniors and People with Disabilities Think for a moment about your experience with disability or the functional limitations seniors might experience. What is Disability? Disability can become a fact of life for anyone, at anytime; As we age, the likelihood of having a disability or functional limitation increases; Disability is neither inability nor sickness. 11

12 What is Disability? The interaction of physical, sensory or cognitive impairment with environmental factors. Disability, functional limitation and chronic conditions co-exist and cut across among Medi-Cal beneficiaries. Chronic conditions, diseases and disabilities Functional Limitations Accommodations 12 12

13 Age Distribution of New Enrollees: Age Percent Under 1 Year 0.9% 1-9 Years 5.2% Years 9.6% Years 24.6% Years 44.6% Years 10.3% Years 4.5% 85 + Years 0.9% 13

14 Prevalent Health Condition Characteristics of SPD s according to Center for Health Care Strategies Health Condition Percent Cardiovascular 28.4 Diabetes 12.7 Gastrointestinal 15.6 Renal 8.5 Central Nervous System 22.7 Pulmonary 19.8 Skeletal and Connective Tissue 17.6 Skin 8.1 Behavioral Health 29.3 Eyes

15 Need for Case Management As beneficiaries enter managed care over the next year, you will see more case management in the areas of: Behavioral health Substance abuse Intellectual and developmental disabilities Cognitive disabilities (e.g., autism spectrum disorder) Chromosomal disorders (e.g., Downs syndrome) Physical development or neuromuscular disabilities (e.g., Cerebral palsy) Chronic medical conditions (may be multiple chronic conditions) Pregnancy with an identified disability End stage renal disease Recent organ transplant Cancer and current treatment Antipsychotic medications 15 15

16 Profile of Seniors and People with Disabilities Profile of Medi-Cal Seniors: Seniors represent about 14% of Medi-Cal beneficiaries who have no other insurance who will experience mandatory enrollment into managed care during About two-thirds of seniors in Medi-Cal, and who will have no other insurance, have disabilities Based on prevalence of disability among seniors, most seniors in Medi-Cal, who have no other insurance are likely to have some type of functional limitation 16

17 Profile of Medi-Cal Beneficiaries with Disabilities 70% who have disabilities live with two or more chronic conditions About 25% have four or more chronic conditions 30% of beneficiaries with disabilities receive treatment for mental health conditions annually 17

18 Healthcare Disparities 70% of people with disabilities have multiple chronic conditions People with Disabilities General Population(Non- Disabled) Diabetes 16% 7% Overweight/Obese 30% 19% Smokers 40% 22% 18

19 Healthcare Disparities Disparities of Women with Disabilities Mammogram (40 Years or greater) Had Pap within last 3Years Woman with Severe Mobility Impairments Women without reported Disability 72.2% 78.8% 78.9% 83.4% Depression 30% 8% Diabetes 36.3% 7.1% Osteoporosis 25.5% 5.3% Obesity 47.6%

20 Barriers to Accessing Care Physical (facility) barriers Access to your facility Access to exam rooms or lab areas Access to Restrooms Communication barriers Qualified ASL Interpreters Relay Service Assistive Listening Device Text Messaging Availability of Materials in Alternate Formats, (Braille, Audio, Large Font, etc) Visual Language Translator 20

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23 Barriers to Accessing Care Equipment barriers Height Adjustable Exam Table Wheelchair Weight Scale Hoyer Lift Accessible Mammography Equipment Moveable Optometry or Podiatry Chairs Practitioner awareness barriers Need for ongoing Provider Training and Resources Access to Disease Prevention and Health Promotion Programs and Services Resulting in less participation in prevention program that people without disabilities 23

24 Negative Phrases The disabled, The handicapped Retarded, mentally handicapped The blind The deaf, a hearing loss Afflicted by multiple sclerosis Positive Phrases Person with a disability Persons with intellectual or cognitive disabilities Person who is blind, person who is visually impaired. Person who is deaf; person who is hard of hearing Person who has multiple sclerosis Cerebral palsy victim Person with cerebral palsy Epileptic Person with epilepsy Confined to a wheelchair; wheelchair bound Wheelchair user; person who uses a wheelchair Crippled, lame, deformed Person with a physical disability Dumb, mute Unable to speak, uses synthetic speech Fit Seizure Crazy; nuts Person with a psychiatric disability or mental illness Admits he/she has a disability Says he/she has a disability Suffers from a disability, victim Person has a disability Midget/Dwarf Person with short stature Normal or Healthy Kid Kid (Person) without a disability Handicapped Parking; Handicapped Bathroom Accessible Parking; Accessible Bathroom 24

25 Common Misconceptions & Stereotypes Myth People with Disabilities are Brave and Courageous Having a disability means you cannot be healthy. Wheelchair use is confining. Users of wheelchairs are wheelchair bound. People with Developmental Disabilities cannot contribute to their community All Deaf People Read Lips Fact Adjusting to a disability actually requires adapting to a lifestyle, not bravery or courage Persons with disabilities experience good health and full participation in community life. They benefit from the same health enhancing activities such as preventative care, diet programs, exercise, as people without disabilities A wheelchair, much like a bicycle, or automobile, is an assistive device that enables mobility it is liberating, not at all confining. Medical Professionals often lack experience and training when treating people with developmental disabilities. Outdated ideas may guide treatment decisions If English is a 2 nd Language for a person who is deaf they may not read lips, or write notes. Women with Disabilities are not sexually active Physicians need to ensure women s reproductive needs are met; that includes providing education, appropriate testing and contraception 25

26 III. Molina s Programs and Services Bridge 2 Access Program Molina s program that focuses on improving access to existing healthcare services for seniors and persons with disabilities. 26

27 Bridge2Access Strategies Basic Medi-Cal Benefits 24-hour Nurse Advice (TTY Accessible) Communication Access Interpreter Services (foreign & sign language) Improved Physical Access (PARS Tool-Part of FSR) Coordinated Care for multiple conditions Weight Loss & Smoking Cessation programs Chronic Disease Management Programs Transportation Services Develop Network of Community Supports Services Disability Awareness/Sensitivity to Staff and Network Statewide Advisory Committee of Disability Advocates 27

28 Access: Physical

29 Access: Physical & Communication

30 IV. Coordinating Accommodations What YOU can do in your office > Flexible Appointment Times > Longer Appointment Times Communication Care Management > Chart Sheets that Identify Accessibility needs Capture information about required accommodations Designated place in Patient chart easily found If applicable add to electronic health record 30

31 Coordinating Accommodations What you can do in your office (continued) > Arrange Sign Language Interpreters (before appt.) Make sure you have Procedure available for each Health Plan > Provide assistance to complete forms(in Private) Visual Disability or Blind Spasticity (CP, etc) > Allow Service Animals > Provide Alternate and Accessible Formats > Think outside the box Be Creative 31

32 Coordinating Accommodations What the Health Plan Can Do > Assistance with arranging sign language interpreters > Provide materials in alternate/accessible formats; (Braille, Large Font, Audio, etc.) > Provide resources for accessible equipment, i.e., assistive listening devices, height adjustable weight scales, Hoyer lifts. > Provide ongoing Disability Awareness/Sensitivity training and materials > Assistance with Care Management/Complex Case Management 32

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