Optum s Role in Mycare Ohio

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1 Optum s Role in Mycare Ohio

2 What is MyCare Ohio? New opportunities generated by the Affordable Care Act have allowed Ohio to implement the MyCare Ohio program. MyCare Ohio is a demonstration project that integrates Medicare and Medicaid services into one demonstration waiver, operated by a Managed Care Plan. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 2 2

3 Comprehensive, Team Based, Person Centered Approach Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 3 3

4 Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 4 4

5 Overview of Optum Optum, a health services company, partners with insurance companies to bring specialized clinical support and provider relations expertise to skilled nursing facilities Optum provides a patient-centric, treat in place clinical model led by clinicians to coordinate and enhance the quality of care for nursing home residents. Health Plan Family/Responsible Party Resident Optum Nurse Practitioner Optum Medical Director Activities Director Primary Physician Director of Nursing Business Office Social Services Facility Administrator Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 5

6 Optum Clinical Process Onsite Clinician Intensive Delivery of Primary Care Treat in Place Our clinical team delivers care in conjunction with the PCP and the facility staff. Evaluates and manages the care of enrollees in conjunction with the family, Trans-Disciplinary care team, and any involved specialties. The NP (or PA) also provides onsite formal & informal education to facility staff. RN or LPN assists NP in the development and implementation of the Care Plan. Identify and treat a patient s change in condition early by providing appropriate medical management, prevents unnecessary hospitalizations. Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 6

7 Program Overview: Full MyCare Ohio Clinical Model (Opt-In) Population Long-term stay Beneficiaries who are covered for both Medicaid and Medicare services ( Engaged Members ) Who is delivering the program? Optum NP Conducts Clinical Assessment Orders diagnostic and laboratory tests Orders pharmacological and non-pharmacological therapy and treatment Manages the medical care of the patient in collaboration with the PCP Optum RN Develops the Comprehensive Assessment and Care Plan Coordinates communication with the family and the responsible party of the engaged member Coordinates Services for the engaged member, i.e. Transportation Coordinates with the Health Plan on appropriate benefits Optum LPN Contribute to the completion of the Comprehensive Assessment and development of the Care Plan Coordinates communication with the family and the responsible party of the engaged member Coordinates Services for the engaged member, i.e. Transportation Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 7

8 Program Overview: Full MyCare Ohio Clinical Model (Opt-In) What will Optum do? (In addition to Medicaid Model) NP will make scheduled and unscheduled visits to medically manage the patient A comprehensive medication review with the goal of reducing high risk medications. Identify Outpatient Services (including Psychiatric) that may be required Hospitalization follow up to ensure a smooth transition back to the SNF and visit with member. Visit includes a new Comprehensive Bi-Psycho-Social Assessment, medication review, and hospital order review. NP will recommend members to be reviewed by Trans-Disciplinary Care Team for Hospice eligibility. Benefits and Goals of the Program Support patients and partners through coordinating/providing an improved quality of services and care Improve performance on relevant HEDIS, HOS, MDS and other prioritized quality indicators, including Star ratings. Support patient safety Support Healthcare quality and affordability through continuous quality improvement as a core competency. Improve efficiencies supporting quality initiatives. Expedited diagnostic test results Meet State, Federal, and regulatory requirements for model of care and quality improvement Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 8

9 Program Overview: Medicaid Clinical Model (Opt-Out) Population Long-Term stay MyCare Beneficiaries who are covered for Medicaid services Who is delivering the program? Optum LPN Contributes to the completion of the Comprehensive Assessment and development of the Care Plan Coordinates communication with the family and the responsible party of the engaged member Coordinates Services for the engaged member Optum RN Develops the Comprehensive Assessment and Care Plan Coordinates communication with the family and the responsible party of the engaged member Coordinates Services for the engaged member, i.e. Transportation Coordinates with the Health Plan on appropriate benefits Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 9

10 Program Overview: Medicaid Clinical Model (Opt-Out) What will Optum do? Complete the Comprehensive Assessment Update the Comprehensive Assessment as appropriate or as dictated in the 3-way agreement Develop and maintain the Care Plan Complete assessment for repatriation as appropriate and communicate results to our Health Plan partners and trans-disciplinary team for further action Maintain the minimum contact schedule outlined in the 3-way agreement Benefits and Goals of the Program Provide improved Comprehensive Care Management and communication Identify appropriate individuals who would be good candidates for repatriation Identify candidates for appropriate additional services (i.e. Behavioral Health) Coordinate with Health Plan Case Managers as appropriate Disease management education for the patient Enhanced communication with the family Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 10

11 Program Overview: Repatriation Population Long-term stay MyCare Beneficiaries who are covered for Medicaid services and those that are full MyCare Ohio participants ( Engaged Members ) Program Focus: Identify members who are potentially eligible for repatriation, Optum will not be responsible for the actual transfer Who is delivering the program? Optum LPN/RN Completes the Repatriation Assessment Coordinate with Health Plan Care Manager Coordinates communication with the family and the responsible party of the engaged member Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 11

12 Program Overview: Repatriation Program Goals Identify good candidates for repatriation Develop plan and process for discharge Remain compliant with State and Federal requirements Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 12

13 Program Overview: Post Acute Skilled (PAS) Population Short-term stay MyCare Beneficiaries who are covered for both Medicaid and Medicare services ( Engaged Members ) Who is delivering the program? -Sees the enrolled patient after SNF arrival, and a progress focused note is completed -Develops an initial plan of care upon admission and address Advance Care Directives and health care proxy -Makes initial contact within 48 hours of admission to the SNF with follow-up visits occurring as needed until discharge -Collaborates and Coordinates with the Trans Disciplinary Care Team to proactively monitor patients skilled care and progress towards rehab goals and prevent hospital readmission Optum NP -Provides first call coverage -Ensures accurate diagnosis coding to assist RAF improvement -Writes a final progress note on each enrolled patient and sent to the patient s Primary Care physician upon SNF discharge -Coordinates with the Trans-Disciplinary Care Team to notify waiver services in the event of additional required services to aid in the transition back to community Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 13

14 Program Overview: Post Acute Skilled (PAS) What will Optum do? NP will make visits to the patient while they are in short stay/rehab Visits will focus on preventing re-hospitalization, managing length of stay appropriately and returning the patient home with a medical plan of care Optum RNs and LPNs will work in collaboration with the NP and the Trans- Disciplinary Care Team to coordinate communication and services Benefits and Goals of the Program Prevent unnecessary re-hospitalization Manage length of stay with a goal of less than 20 days Improve Quality Ratings Work with the TCT to support and help coordinate the patient s transition to home Confidential property of Optum. Do not distribute or reproduce without express permission from Optum. 14

15 Q & A Confidential property of Optum. Do not distribute or reproduce without express permission from Optum

16 Thank You

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