A 3-year initiative to assess the network of providers that will integrate

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1 Comparison of Key Aspects of California s Health Home and Whole Person Care Pilot Initiatives with the California Accountable Communities for Health Initiative March 2016 This document summarizes the similarities and differences between three pending initiatives: 1) Health Homes for Patients with Complex Needs Program 1, 2) Whole Person Care Pilots 2, and 3) Accountable Communities for Health Initiative. Although these three initiatives focus on different populations, they each recognize the importance of addressing both the clinical and nonclinical needs of an individual and that the collaboration and coordination of programs and agencies is critical for health systems transformation. Given the overlapping timeframes, the many similarities in approach, and the potential for overlapping geographies, we are providing this comparison of the three initiatives. It draws from the analysis recently released by the California Department of Health Care Services (DHCS) that compared the Health Homes Program, Whole Person Care Pilot, Public Hospital Redesign and Incentives in Medi-Cal Program (PRIME) and the Coordinated Care initiative; we have excerpted key elements for this document. For the full side-by-side prepared by DHCS, see: Summary Health Home Program (HHP) Whole Person Care (WPC) Pilots California Accountable Communities for Health Initiative (CACHI) An ongoing initiative to develop a A 3-year initiative to assess the network of providers that will integrate feasibility, effectiveness, and potential and coordinate primary, acute, and value of a more expansive, connected behavioral health services for the and prevention-oriented health system. highest risk Medi-Cal enrollees. A 5-year, up to $1.5 billion federally funded pilot program to test countybased initiatives that coordinate health, behavioral health, and social services for vulnerable Medi-Cal beneficiaries who are high users of multiple systems and have poor outcomes. An ACH aims to 1) improve communitywide health outcomes and reduce disparities with regard to identified 1 For more Health Home info: 2 For more Whole Person Care info: 1

2 Authority Section 2703 of the ACA established a new optional Medicaid state plan benefit covering health home services for beneficiaries with chronic conditions. California Assembly Bill (AB) 361 (2013) authorized DHCS to submit a State Plan Amendment to establish a HHP. The Medi-Cal 2020 Section 1115 Waiver authorized the creation of WPC pilots. health needs; 2) reduce costs associated with the health care and, potentially, non-health sectors; and, 3) develop financing mechanisms through a selfsustaining Wellness Fund, to sustain the ACH and provide ongoing investments in prevention and system-wide efforts to improve population health. CACHI is authorized and funded by three funders: The California Endowment, Blue Shield of California Foundation, and Kaiser Permanente. It builds on a proposed initiative originally developed and included as part of the State Health Care Innovation Plan under the federal State Innovation Model grant. Lead Entities Participating Entities Medi-Cal managed care plans (MCPs) will organize the payment and delivery of services. In counties that implement HHP, Medi- Cal plan and Cal MediConnect plan participation will be mandatory. Plans certify and contract with Community-Based Care Management Entities (CB-CMEs), which may include hospitals, clinics, physicians, local health departments, community mental health centers, and/or substance use disorder treatment providers. Each WPC pilot will have a lead entity that will be a: county agency; city and county; health or hospital authority; designated public hospital; district municipal public hospital; a consortium of any of the above entities The WPC pilot applications identify other entities [in addition to the lead entity] that will participate in the WPC pilot. Participating entities must include a minimum of: One Medi-Cal managed care health plan (MCP) operating in the geographic The Lead Applicant must be able to perform the fiduciary and administrative functions and be either a non profit or public organization. The Lead Applicant can be the Backbone organization or it can be a separate organization. The ACH collaborative must include: Health plans, hospitals, private providers or medical groups and community clinics serving the geographic area; government health and human services agency/public health department; grassroots, 2

3 County mental health plans and county substance use disorder agencies that participate in the Drug Medi-Cal waiver have the option to serve in the MCP and/or CB-CME role for HHP beneficiaries with conditions that are appropriate for specialty behavioral health treatment. area of the WPC pilot; Both the health services and specialty mental health agencies or department; At least one other public agency or department, which may include county alcohol and substance use disorder programs, human services agencies, public health departments, criminal justice/probation entities, and housing authorities (regardless of how many of these fall under the same agency head within a county); and At least two other key community partners that have significant experience serving the target population within the participating county or counties geographic area, such as physician groups, clinics, hospitals, and community-based organizations. community and social services organizations that include authentic and diverse representation of residents, particularly from underserved communities. It is desirable to include broad representation such as: County and/or city government leadership, including elected officials; behavioral health providers; housing agencies; food systems; employers and other business representatives; labor organizations; Faith-based organizations; schools and educational institutions; parks and recreational organizations and agencies; transportation and land use planning agencies; dental providers; local advocacy, grassroots organizations or policy-focused organizations Target Population California s HHP targets the top 3-5% highest risk Medi-Cal beneficiaries with the best opportunity for improved health outcomes through HHP services. HHP chronic condition eligibility criteria include: At least two of the following: asthma, chronic obstructive pulmonary disease If a lead entity cannot reach agreement with a required participant, it may request an exception to the requirement. WPC pilots identify Medi-Cal beneficiaries who are high-risk high users of multiple health care systems in the geographic area they serve. By sharing data among participating entities, WPC pilots identify common beneficiaries and define the target population(s), which may include, but are not limited to individuals: All residents in a targeted community/geography with focus on equity. Communities are encouraged to select a health need, chronic condition, set of related conditions, or community condition that has broad support among collaborative partners and residents and 3

4 (COPD), diabetes, traumatic brain injury, chronic or congestive heart failure, coronary artery disease, chronic liver disease, dementia, substance use disorder OR Hypertension and one of the following: COPD, diabetes, coronary artery disease, chronic or congestive heart failure OR One of the following: major depression disorders, bipolar disorder, psychotic disorders (including schizophrenia) In addition, criteria will specify that the member must also have: A chronic condition predictive risk score above three based on a specific riskscoring tool selected by DHCS OR At least one inpatient stay in the last year OR Three or more emergency department (ED) visits in the last year The following additional criteria are applicable: At least two separate claims for the eligible condition Enrollment cannot be capped. However, states can operate the program only in certain geographic regions and define the eligible target populations with repeated incidents of avoidable emergency use, hospital admissions, or nursing facility placement; with two or more chronic conditions; with mental health and/or substance use disorders; who are currently experiencing homelessness; and/or individuals who are at risk of homelessness, including individuals who will be experiencing homelessness upon release from institutions (hospital, sub acute care facility, skilled nursing facility, rehabilitation facility, Institution for Mental Disease, county jail, state prisons, or other). The number of individuals served may be limited at the discretion of the pilot and upon approval by DHCS. with which members already have experience. Communities often characterize their chosen priority in different ways - the examples below are one approach: A health need priority: tobacco use, obesity A chronic condition priority: asthma, diabetes, depression A community condition: family and community violence, lead A set of related conditions: cardiovascular + diabetes; air quality + asthma; diabetes + depression Suggested criteria for selecting any selected issue should include being: Amenable to having interventions, which are evidence-based to the greatest extent possible, across the five domains, and Inclusive of a variety of populations within a community, not just high need, high cost populations. There is no prescribed geographic size, but similar initiatives are between 100,000 and 200,000. The geography should: include sufficient partners and services to reach the majority of the population; include areas of significant 4

5 Strategies/ Services HHP will provide reimbursement for care coordination services/benefits. There are six categories of required services: comprehensive care management; care coordination and health promotion; comprehensive transitional care; patient and family support; referral to community and social support services; and the use of health information technology to link services, as feasible and appropriate. The most recent HHP concept paper released by DHCS in December 2015 further defines these services and delineates the specific responsibilities of the MCPs and CB-CMEs. HHP enrollees will have an individualized care plan and a care manager that ensures access to all needed services across the spectrum of care and support. The HHP only funds the care WPC Pilots will design and implement specific strategies to: Increase integration among county agencies, health plans, and providers, and other entities within the participating county or counties that serve high-risk, high-utilizing beneficiaries, and develop an infrastructure that will ensure local collaboration among the entities participating in the WPC pilots over the long term; Increase coordination and appropriate access to care for the most vulnerable Medi-Cal beneficiaries; Reduce inappropriate emergency and inpatient utilization; Improve data collection and sharing among local entities to support ongoing case management, monitoring, and strategic program improvements in a sustainable fashion; Achieve targeted quality and administrative improvement benchmarks; Increase access to housing and disparities with respect to the selected health issue; be large enough to demonstrate impact; and, small enough to ensure that the scale of the interventions proposed can address the identified issue(s). Core elements include: Shared vision and goals: A common set of goals and vision, based on a shared understanding of the problem. Partnerships: Meaningful collaboration among the health care, social services, and various community agencies and sectors dedicated to achieving the vision and goals. Leadership: At least one, but ideally several, champions at both an individual and organizational level among the core entities of an ACH. Backbone: An agreed upon entity that will serve as collaborative s facilitator and convener. Data analytics and capacity: The infrastructure, capacity and agreements for collecting, analyzing and sharing financial, community and population-level data across a variety of providers and organizations. Wellness fund: a vehicle for attracting resources from a variety of organizations and sectors to support the goals, priorities and strategies developed by the ACH. 5

6 coordination services. HHP does not fund any direct medical or social services. supportive services (optional); and Improve health outcomes for the WPC population. WPC pilots determine the specific services that will be provided and the interventions and strategies that will be implemented to meet the goals outlined above. WPC pilots cannot duplicate beneficiaries as the HHP. However, the same services could be provided through both the WPC pilot and HHP if the programs target different populations. Lead entities will provide this information in the application. ACHs will implement a portfolio of interventions to address the selected health issue. A portfolio consists of a set of coherent mutually-supportive interventions that address a particular issue or conditions across five key domains: clinical care, community programs and social services, community-clinical linkages, environment, and public policy and systems. Implementation Timeframes Phased-in implementation, pending CMS approval of the HHP State Plan Amendment: Group 1: January 2017 Group 2: July 2017 Group 3: January 2018 Some counties are not scheduled for implementation at this time (See appendix for phase-in plan). Program is permanent WPC pilots may offer HHP services if no HHP is operating in the pilot county, or for people who are not eligible for HHP services. In either case, WPC pilots may also offer care coordination services that go beyond what is offered in the HHP. Anticipated timeline: Attachments to Special Terms and Conditions finalized in March Application, selection criteria, and timelines released: May 16, WPC pilot applications due: July 1, 2016 (45 days after application release). The RFP was released on January 22, 2016, and applications are due on April 29, The projected start date is July 1,

7 Program Duration Financing subject to demonstrating no net impact to the state General Fund. Ongoing 90 percent federal matching funds are available for the first eight quarters of HHP, and are subsequently reduced to 50% federal match for the population that was eligible for Medicaid benefits pre Individuals eligible through the Medicaid optional expansion will continue to receive 100% FMAP for health home services, with the match gradually decreasing to 90% in year program Years: January 1, 2016 December 31, 2020 Up to $1.5 billion in federal funding for WPC pilots through the Medi-Cal 2020 waiver. Up to $300 million may be distributed in the first year. Individual pilots are limited to receiving a maximum of 30% of the total allowable funding. WPC pilots provide local match through permissible sources of intergovernmental transfers. 3-year program No federal financing. Foundation funding of up to $850,000 per site (up to six sites) over three years as follows: Year 1: up to $250,000 per site Years 2 and 3: up to $300,000 per site No Match is required 7