Presented to: Long Term Care Workgroup May 26, 2011

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1 Presented to: Long Term Care Workgroup May 26, 2011

2 Partners in the Grant SC Department of Health and Human Services Sam Waldrep Roy Smith Project Coordinator Office of Research and Statistics Institute for Families in Society/USC Dr. Ana Lopez-De Fede Kathy Mayfield-Smith College of SW/School of Medicine/SmartHome Dr. Sue Levkoff College of Pharmacy Dr. Sarah Ball

3 Federal Initiative for Dual Eligible People CMS created the Federal Coordinated Health Care Office, or the Duals Office Affordable Care Act impetus Will work with the states to implement the top strategies to coordinate and integrate primary, acute, behavioral and long-term supports and services for dual eligibles, improving quality and lowering costs.

4 The Goals of Integrated Care Creates a single point of accountability for the delivery, coordination and management of primary/preventive, acute, behavioral, and long-term supports and services Promotes and measures improvements in health outcomes Promotes the use of home- and community-based longterm supports and services Blends/aligns Medicare and Medicaid s services and financing to streamline care and eliminate cost shifting Slows the rate of both Medicare and Medicaid cost growth AND, most importantly Provides better care for beneficiaries that is sensitive to their needs and preferences

5 Integration can improve care and outcomes by: Looking for area of high overlap between Medicaid and Medicare, duplication, avoidable utilization, gaps in care, etc. Inpatient hospital Home Health SNF and NF Pharmacy Coordinating Medicare hospital discharge planning with Medicaid HCBS Improving transitions between institutional and community settings, such as hospital and home, hospital and nursing facility, nursing facility and home

6 Challenges to Integrated Care Administrative and operational hurdles Lack of good data (access to, analysis of and linkage between Medicare and Medicaid) Financial misalignments between Medicare and Medicaid Enrollment issues Stakeholder (advocates, providers) concern Network adequacy (especially LTSS)

7 SC s Dual Eligible Demonstration Grant Funded through the Center for Medicaid and Medicare Innovation One of 15 states funded One year planning grant Goals of the program: eliminate duplication of services expand access to needed care, and improve the lives of dual eligibles, while lowering costs.

8 SC s Dual Eligible Population 16 percent of SC Medicaid enrollment 50 percent of SC Medicaid expenditures 149,000 enrolled SC Medicaid (FY2010) Only 18% receive some form of care coordination or case management 15,783 in Community Choices Waiver 2,369 (15%) with behavior health diagnosis 11,319 in managed care 3,032 (27%) with behavior health diagnosis

9 Proposed Approach Develop an integrated model of care for dual eligible Build on the Health Home option (ACA) Integrate primary care and behavioral health services Provide linkages to community based long term care services, including family support services

10 Proposed Target Population Dually eligible for Medicaid and Medicare Have behavioral health diagnosis or Alzheimer s Disease Impaired activities of daily leaving Increased need for caregiver support Limited self-directed care or choice of living arrangements Duration of 2 or more years Requires ongoing supervision and prescription of medications for behavioral health diagnosis

11 Major Project Deliverables Design a model that: integrates delivery of primary care, behavioral health care, long-term services and payment sources Improves quality, coordination and cost-effectiveness for dual eligible people Develop a five year demonstration proposal and implementation plan

12 Design Components Organization structure Target population Service delivery Financing Evaluation Implementation Legislative issues

13 Expected Outcomes of System Create a single point of accountability for the delivery, coordination and management of primary/preventive, acute, behavioral, and long-term supports and services Improve health status/health outcomes and quality of life by providing a Health Home Seamless coordination of benefits between Medicare and Medicaid funding streams. Increased length of time between, and reduced number of hospitalizations and ED visits for treating chronic illness, complications or mental health conditions

14 Expected Outcomes (cont) Improved timely access to primary care and specialty care services for initial and ongoing monitoring and treatment Payment structure that blends/aligns Medicare and Medicaid s services and financing to streamline care and eliminate cost shifting Mechanism to enable SC to share in Medicare savings

15 Potential Service Components Health Home services including: comprehensive care management; care coordination and health promotion; comprehensive transitional care from inpatient to other settings, including appropriate follow-up; individual and family support, including authorized representatives; referral to community and social support services; and use of health information technology to link services. Enhanced primary care multidisciplinary team, medical management including disease management, medication management and education (SCORxE); LTC services/supports and family and social services (e.g., respite)

16 Potential Service Comp. (cont) Major components of the integrated behavioral/ mental health services include: screening (form possibly built into Phoenix and sent to the primary care physician); various models of integration including co-location of behavioral health specialists, collaborative arrangements with community based providers, and psychiatric consultation by phone or via telepsychiatry.

17 Integrated Care Workgroup Build on the LTC Workgroup Assist to design the model and develop the implementation plan Focused areas for design/development Administrative/Structure/Operation Data analysis Financial (Costs, Align Medicaid/Medicare funding, rate structure, cost shifting)

18 Timelines May 1, 2011: Grant began May June 2011: Hire staff, acquire Medicare data, formalize workgroup July August: Link datasets, extensive data analysis, explore financing options, Workgroup meeting, Sept. November: Complete data analysis, financial modeling, service models; payment models, long-term data planning, explore legislative requirements, SPA, work-group subcommittees, workgroup meeting

19 Timelines (cont) December 2011 January 2012: Develop model design and strategic plan with sub-committees of the Workgroup, agency personnel and contractors. Draft Model Design and Implementation Plan with consumer, legislative and other stakeholders input. February-April 2012: Finalize Model Design and Implementation Plan and submit to CMS.

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