CASE MANAGEMENT COMMITTEE CONFERENCE CALL

Transcription

1 CASE MANAGEMENT COMMITTEE CONFERENCE CALL Thursday, December 10, :00 pm 2:00 pm 1 (800) PASS CODE: #

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3 CASE MANAGEMENT COMMITTEE CONFERENCE CALL Thursday, December 10, :00 PM - 2:00 PM Call-in: (800) ; Passcode: # ITEM SUBJECT REPORTING PAGE *Action Item I. CALL TO ORDER/INTRODUCTIONS Rogers Case Management Committee Roster 3 II. MINUTES OF PREVIOUS MEETING September 9, 2015 Meeting Minutes Rogers 5 Recommendation: approve meeting minutes III. COMMITTEE OPERATIONS A. Membership Update B. Schedule 2016 Meeting Schedule Rogers 7 IV. CURRENT ISSUES A. Discharge Planning Proposed rule CHA Summary of Proposed Rule B. Managed Medi-Cal/ Cal MediConnect/CCI Draft Tool Kit C. PASRR Blaisdell V. NEW BUSINESS A. Agenda Planning - January 20, 2016 All

4 CHA Case Management Committee Meeting December 10, 2015 VI. NEXT MEETING WEDNESDAY, JANUARY 20, :00AM 2:00PM CHA- Board Room 1215 K Street, Suite 800 Sacramento, CA Rogers VII. ADJOURNMENT

5 CASE MANAGEMENT COMMITTEE 2015 Membership Roster MEMBERS Marcy Adelman, RN, CCM, MSN Clinical Resource Management Palomar Health 456 E. Grand Ave. Escondido, CA O: Regina Berman, RN, MA, Vice President, Population Health Management Memorial Care Health System Brookhurst Street Fountain Valley, CA O: Therese Carrabine, RN, MS Case Management & Patient Placement Director Cedars Sinai Medical Center 8700 Beverly Blvd. Suite 2802 Los Angeles, CA O: Heather Esget, RN, BSN, ACM Director of Case Management Shasta Regional 1100 Butte St. Redding, CA O: Theresa Kurtinaitis, MSN, RN Vice President, Case Management SHARP Healthcare 8695 Spectrum Center Blvd. San Diego, CA O: Elizabeth Miller, RN, MSN Executive Director, Care Management Adventist Health 1509 Wilson Terrace Glendale, CA O: Lynne Ashbeck Vice President, Population Health Community Medical Centers 789 N. Medical Center Drive East Clovis, CA O: Diane Brown, PhD, RN, CPHQ, FNAHQ, FAAN Executive Director, Care Coordination Kaiser Permanente, Northern California 1950 Franklin Street, 19 th Floor Oakland, CA O: Karen Dunning Director of Operations, Care Coordination Sutter Health System Offices 2890 Gateway Oaks Drive, Suite250 Sacramento, CA O: Tammy Hoeffel, RN, BSN Director of Case Management, Social Services and Palliative Care John Muir Medical Center-Cross Campus 1601 Ygnacio Valley Blvd Walnut Creek, CA O: Toby Marsh, RN, MSA, MSN, FACHE, NEA- BC Director, Patient Care Services UC Davis 2315 Stockton Boulevard, Suite 4305 Sacramento, CA O: Terri Scott, RN, BSN Regional Senior Director, Care Coordination Dignity Health/Greater Sacramento Service Area 4001 J. St. Sacramento, CA O:

6 2015 Case Management Committee Ricki Stajer, RN, MA, CPHQ Vice President, Care Coordination PIH Health Washington Blvd Whittier, CA O: x12780 Lisa Stroud, RN, MS, PhD (c) Director of Care Management Santa Clara Valley Medical Center 751 South Bascom Avenue San Jose, CA O: Tessie Sulit Wagoner, RN-BC, MHA, BSN, CCM, IQCI Regional Senior Director, Case Management Kindred Healthcare/West Region 200 Hospital Circle Westminster, CA O: REGIONAL ASSOCIATION REPRESENTATIVES Ivonne Der Torosian, MPA, BSM Regional Vice President-Central Valley and Central Coast Hospital Council of Northern and Central California 1625 E. Shaw, Suite 139 Fresno, CA O: Julia Slininger, RN, BS, CPHQ Vice President, Quality and Patient Safety Hospital Association of Southern California 515 Figueroa Street, Suite 1300 Los Angeles, CA O: Judith Yates Senior Vice President Hospital Association of San Diego and Imperial Counties 5575 Ruffin Road, Suite 225 San Diego, CA O: STAFF Patricia L. Blaisdell, FACHE Vice President, Continuum of Care California Hospital Association 1215 K. Street, Suite 800 Sacramento, CA O: Debby Rogers, RN, MS, FAEN Vice President, Clinical Performance and Transformation California Hospital Association 1215 K. Street, Suite 800 Sacramento, CA O: Boris Kalanj Director, Cultural Care and Patient Experience Hospital Quality Institute 1215 K Street, Suite 900 Sacramento, CA O: Beth Demeter Administrative Assistant California Hospital Association 1215 K. Street, Suite 800 Sacramento, CA O:

7 CHA CASE MANAGEMENT COMMITTEE MEETING California Hospital Association - Sacramento, CA Wednesday, September 9, :00 am 2:00 pm Present: By Phone: Staff: Regional Association Staff: Marcy Adelman, Diane Brown, Therese Carrabine, Todd Cook, Karen Dunning, Tammy Hoeffel, Theresa Kurtinaitis, Toby Marsh, Elizabeth Miller, Terri Scott, Ricki Stajer, Lisa Stroud Regina Berman, Heather Esget, Tessie Sulit Wagoner Pat Blaisdell, Boris Kalanj, Debby Rogers, Marisa Ward Ivonne Der Torosian, Julia Slininger I. CALL TO ORDER Staff Blaisdell and Rogers called the meeting to order at 10:05 am. II. COMMITTEE OPERATIONS A. Operating Guidelines Staff Blaisdell and Rogers reviewed the draft operating guidelines and requested input. The committee shall consist of no more than 25 voting members. The committee agreed to meeting four times a year, face to face, with additional conference call meetings as indicated. III. COMMITTEE MISSION A. Mission Statement Committee members discussed the draft mission statement for the Case Management Committee. Based on input from participants, the following mission statement was developed and agreed upon. The mission of the Case Management Committee is to provide leadership within the hospital and health care community to promote policy and advocacy that supports the safe and sustainable delivery of clinically beneficial and operationally sound case management, transition planning and care coordination. 5

8 CHA Case Management Committee Meeting Summary 2 IV. IDENTIFICATION OF PRIORITY ISSUES A. Key case management issues Committee members were asked to identify key issues and challenges for case managers in their organizations. The following list of issues was developed: Emergency Department/Difficult to place End of Life patients Bundled payment models Unrepresented patient Risk stratification across a continuum Payer blind Observation/ Two-midnight policy Data management Uninsured/Underinsured/Undocumented Staffing/Case load Payer accountability Social determinacies of health Managed Medi-Cal Partnership with HCBS Inadequate primary care access Payment for necessary care LTCH approvals Admissions from SNFs PASRR DME SB 675 FSED Access to custodial beds Mental illness/substance abuse Homeless/Housing Disparities of outcomes Workface development Services for vulnerable Population Health populations. V. ACTION PLAN DEVELOPMENT Committee members were asked to prioritize the issues list, and identified the following issues as highest priority: 1. Working with managed Medi-Cal plans (including Cal MediConnect/CCI ) 2. Access to services for individuals with mental illness or substance use disorders 3. Access to primary care services 4. Implementation of observation/ two-midnight policy VI. NEXT STEPS The following next steps for committee activity were identified, and will be facilitated by Rogers/Blaisdell 1. Four committee meetings will be scheduled for A conference call meeting will be held prior to the end of the year to provide updates and support planning for Members who are interested in serving as chair are encouraged to contact Blaisdell or Rogers. VII. ADJOURN Staff Blaisdell and Rogers adjourned the meeting at 1:59 pm.

9 CASE MANAGEMENT COMMITTEE 2016 Meeting Dates WEDNESDAY, JANUARY 20, :00AM 2:30PM CHA- Board Room 1215 K Street, Suite 800 Sacramento, CA WEDNESDAY, MARCH 30, :00AM 2:30PM CHA- Board Room 1215 K Street, Suite 800 Sacramento, CA WEDNESDAY, JUNE 22, :00AM 2:30PM CHA- Board Room 1215 K Street, Suite 800 Sacramento, CA WEDNESDAY, SEPTEMBER 28, :00AM 2:30PM CHA- Board Room 1215 K Street, Suite 800 Sacramento, CA Wednesday, November 16, :00am 11:00am Conference Call: (800) Pass Code: # 7

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11 December 10, 2015 TO: FROM: SUBJECT: Case Management Committee Members. Pat Blaisdell, VP Continuum of Care Debby Rogers, VP Clinical Performance and Transformation Discharge Planning Proposed Rule SUMMARY The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule revising the discharge planning requirements for hospitals and home health agencies. ACTION REQUESTED To provide an update regarding and solicit input regarding proposed changes to hospital and home health requirements for discharge planning. DISCUSSION The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 required revisions to the conditions of participation (CoPs) for all hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals (CAHs) and for home health agencies. Under the proposed rule, hospitals and CAHs would be required to develop a discharge plan within 24 hours of admission or registration and complete a discharge plan before the patient is discharged home or transferred to another facility. This requirement would apply to all inpatients and certain types of outpatients, including patients receiving observation services. CHA will submit a comment letter on the proposed rule on behalf of members. Comments are due on January 4. 9

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13 Medicare and Medicaid Programs: Revisions to Requirements for Discharge Planning for Hospitals, Critical Access Hospitals and Home Health Agencies Summary of Proposed Rule November 2015 The Centers for Medicare & Medicaid Services (CMS) has published in the November 3 Federal Register a proposed rule on Medicare and Medicaid requirements for discharge planning for hospitals, including long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), critical access hospitals (CAHs) and home health agencies (HHAs). The proposed rule can be found at CMS issued this proposed rule in order to modernize discharge planning requirements and bring them into closer alignment with current practice, to help improve quality of care and outcomes and to reduce avoidable complications, adverse events and readmissions. Comments on the proposed rule are due January 4, CHA will host a members-only call on December 11 from 11:00 a.m. to 12:30 p.m. (PT) to review and discuss the proposed rule, in anticipation of submitting comments. Members may register by contacting Beth Demeter at bdemeter@calhospital.org or (916) CHA will provide a draft comment letter prior to the comment deadline for use by members. Additional details on submitting comments are noted at the end of this summary. BACKGROUND CMS describes the rationale for discharge planning and its role in reducing avoidable hospital readmissions and patient complications. In addition to noting that transitions to post-acute care (PAC) settings and to the home present increased risks to patients, CMS states that hospitals and CAHs need to improve their focus on patients with psychiatric and behavioral health problems, including substance use disorders. CMS also reviews the provisions mandated by the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, including the requirement that hospitals and certain PAC providers account for quality, resource use and other measures in assisting patients and their families during the discharge planning process. Compliance with these requirements will be assessed through onsite surveys by CMS, state survey agencies or accrediting organizations with a CMS-approved accreditation program. The proposed rule amends 42 CFR 482, 484, and 485, which address requirements for discharge planning in hospitals (including LTCHs and IRFs), home health agencies and critical access hospitals, respectively. A separate proposed rule, Reform of Requirements for Long Term Care Facilities, which was published on July 16, 2015, addresses discharge planning requirements for skilled nursing facilities as well as other proposed changes. CHA has submitted comments on that proposed rule on behalf of members; a copy of the letter is available at HOSPITAL AND CRITICAL ACCESS HOSPITAL DISCHARGE PLANNING CMS describes hospital discharge planning as a process that involves determining the appropriate posthospital discharge destination for the patient; identifying what the patient requires for a smooth and safe transition from the hospital to his/her discharge destination; and beginning the process of meeting the patient s identified post-discharge needs. CMS believes that providing more specific requirements for 11

14 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 2 actions that must be taken by hospitals prior to the patient s discharge or transfer to a PAC setting would lead to improved transitions of care and patient outcomes. Specific to critical access hospitals, CMS notes that there is no current regulation on discharge planning Conditions of Participation, though CAHs are currently required to arrange for, or refer patients, to needed services that cannot be furnished at the CAH. CMS proposes new standards for CAHs that are similar to those for hospitals. CMS proposes the following changes and revisions to hospital and CAH discharge planning requirements: Design A new proposed standard, Design, would require the discharge planning process policies and procedures to be: (1) developed with input from the hospital s medical staff, nursing leadership as well as other relevant departments; (2) reviewed and approved by the governing body; and (3) specified in writing. Applicability CMS observes that the current discharge planning process requires hospitals to identify patients for whom a discharge plan is necessary, but does not necessarily lead to a discharge plan for all patients. CMS believes that this process results in some patients leaving the hospital without adequate preparation. Under the provisions of the proposed rule, hospitals would be required to provide specific discharge instructions for the following: All inpatients, Outpatients receiving observation services, Outpatients undergoing surgery or other same day procedures for which anesthesia or moderate sedation is used, ED patients identified by the ED practitioner as needing a discharge plan, and Any other category of outpatients as recommended by the hospital s medical staff and specified in hospital policies and procedures. Personnel CMS would combine and revise two existing requirements to specify that a registered nurse, social worker or other personnel qualified in accordance with the hospital s discharge planning policy, coordinate the discharge needs evaluation and the development of the discharge plan. Initiation of plan Under the proposed rule, hospitals would be required to begin identification of the anticipated discharge needs for each applicable patient within 24 hours after admission or registration. The process would be completed prior to discharge home or transfer to another facility and without unduly delaying the patient s discharge or transfer. The same standards would apply if the patient s stay was less than 24 hours. CMS notes that this policy would not apply to emergency-level transfers for patients who require a higher level of care. Ongoing review The hospital s discharge planning process would be required to ensure ongoing patient evaluation throughout the patient s hospital stay or visit, so as to identify any changes in the patient s condition that would require modifications to the discharge plan, and would also be required to document any changes

15 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 3 in a patient s condition that would affect the patient s readiness for discharge or transfer in the discharge plan. Communication with practitioner The patient s practitioner would be required to be involved in the ongoing process of establishing the patient s goals of care and treatment preference, which inform the discharge plan. CMS proposes that hospitals be required to send a copy of the discharge summary within 48 hours of the patient s discharge, and pending test results within 24 hours of their availability. Patient s goals of care and treatment preferences CMS would implement a new requirement that the discharge process address the patient s goals of care and treatment preferences, and that those goals and preferences be taken into account throughout the discharge planning process. The patient and the caregiver/support person(s) would be required to be involved in the development of the discharge plan and informed of the final plan to prepare them for posthospital care. Factors to be considered In developing the discharge plan the hospital would be required to consider several factors, including but not limited to: Admitting diagnosis, Relevant co-morbidities and medical/ surgical history, Anticipated needs post discharge, Readmission risk, Relevant psychosocial history, Communication needs, including language barriers, diminished eyesight and hearing, and selfreported literacy of the patient, patient s representative or caregiver/support person(s), as applicable, Patient s access to non-health care services and community-based care providers, and Patient s goals and treatment preferences. CMS proposes that hospitals consider the availability of and patients access to non-health care services, such as transportation or meal services, and be able to provide additional information on these services. CMS expects hospitals to be well informed of the availability of community-based services and organizations that provide care for patients who are returning home or who want to avoid institutionalization, including aging and disability resource centers, area agencies on aging and centers for independent living. Additionally, CMS encourages hospitals to develop collaborative partnerships with community-based services and organizations and to consider the availability of supportive housing as an alternative to homeless shelters. Caregiver support Under the proposed rule, hospitals would be required to consider the patient s or caregiver s capability and availability to provide the necessary post-hospital care. As part of the ongoing discharge planning process, hospitals would identify areas wherein the patient or caregiver would need assistance and address those areas in the discharge plan. The patient and the caregiver/support person(s) would be required to be involved in the development of the discharge plan and informed of the final plan to prepare them for posthospital care. 13

16 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 4 For individuals being discharged to home, hospitals would be required to provide discharge instructions to the patient and/or caregiver /support person(s) as well as PAC providers or suppliers, as indicated at the time of discharge. CMS states that as a best practice, hospitals should confirm the patient s or caregiver s understanding of the discharge instructions, and consider the use of teach-back when providing discharge instructions. Hospitals would be required to provide patients and caregivers being discharged to home with written information on warning signs and symptoms that may indicate the need to seek immediate medical attention, and what they should do, including whom they should contact, if those symptoms present. Medication reconciliation CMS proposes to require a medication reconciliation process that would include a reconciliation of the patient s discharge medication(s) as well as their pre-hospitalization/visit medication(s), and would require that corrective action be taken to resolve any discrepancies. The medication reconciliation process must be person-centered and incorporate solutions to linguistic, cultural, socio-economic and literacy barriers. For patients being discharged home, the process should also take into consideration how patients will obtain their medications post-discharge. As part of the medication reconciliation process, CMS encourages practitioners to consider using their state s prescription drug monitoring program (state-run electronic databases used to track the prescribing and dispensing of controlled prescription drugs to patients) during the evaluation of a patient s relevant co-morbidities and past medical and surgical history. CMS is soliciting comments on whether providers should be required to consult with their state s prescription drug monitoring program and use its report to review a patient s risk of non-medical use of controlled substances and substance use disorders. The discharge instructions would also be required to include all medications (prescribed and over-thecounter) for use after discharge. The instructions should include name, indication and dosage of each medicine, as well as associated risks and side effects, as appropriate. Follow-up process For patients discharged to home, hospitals would be required to establish a post-discharge follow-up process. CMS does not propose a specific mechanism or timing for the follow-up process, but encourages hospitals to use innovative, low-cost post-discharge tools and technologies where health care providers and caregivers can ask simple questions that help identify individuals at risk for readmissions. Selection of PAC provider The proposed rule modifies and expands current regulations regarding the patient s selection of a postacute care provider. Under the proposed rule, hospitals will be required to provide a list of available Medicare-participating IRFs, LTCHs, HHAs or SNFs to patients for whom such services are indicated. (HHAs would have to request to be listed by the hospital as available.) For patients enrolled in managed care organizations, the hospital would be required to make them aware of the need to verify the participation of providers in their plan network and to share information on provider participation in the managed care organization s network, if that information is known. The hospital would be required to document in the patient s medical record that the list was presented to the patient, and to inform the patient or their caregiver/support person(s) of the patient s freedom to choose among providers and to have their expressed wishes respected, whenever possible. As is currently required, the hospital would have to disclose any disclosure of any relevant financial interest in the providers.

17 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 5 CMS notes that CAHs would be expected to support patients as they choose a PAC setting that meets their goals and preferences, while informing them of the benefits of selecting the most appropriate setting to meet their needs, even if the facility is outside their desired location. The hospital would be required to assist patients, their families or the patient s representative in selecting a PAC provider by using and sharing data on quality and resource use measures for HHA, SNF, IRF or LTCHs. The hospital would have to ensure that the PAC data on quality measures and data on resource use measures were relevant and applicable to the patient s goals of care and treatment preferences. CMS expects that the hospital will document in the medical record that these data were shared with the patient and used to assist the patient during the discharge planning process. The relevant quality measures, as defined in the IMPACT Act, relate to the following domains: standardized patient assessments, including functional status, cognitive function, skin integrity and medication reconciliation. Resource use measures are defined as including total estimated Medicare spending per individual, discharge to community and measures to reflect all-condition risk-adjusted preventable hospital readmission rates. CMS notes that further definition of these terms will be will be addressed in forthcoming regulations or other issuances. However, CMS advises providers to use other sources for information on PAC quality and resource use until the measures stipulated in the IMPACT Act are finalized. Inter-facility transfers Hospitals would continue to be required to communicate necessary information about patients who are discharged or transferred to another facility. While CMS does not propose to mandate a specific transfer form, certain specified information would have to be provided to a receiving facility. At a minimum, this information must include: Demographic information, Contact information for the practitioner, Contact information for the person s caregiver/support person(s), Advance directive, if applicable, Course of illness/treatment, Procedures, Diagnoses, laboratory tests and other specified medically-related information; and Patients goals and treatment preferences, including all other necessary information to ensure a safe and effective transition of care that supports the post-discharge goals of the patient. CMS notes also its proposed continuation of the existing requirement that this information be provided at the time of the patient s discharge and transfer to the receiving facility. CMS solicits comment on the proposed medical information requirements. CMS encourages the use of electronic tools as well as direct communication between the sending and receiving facilities (i.e., clinician-to-clinician). Assessment of discharge planning process The hospital would be required to implement an ongoing, periodic review of a representative sample of discharge plans including those patients who were readmitted with 30 days of a previous admission. CMS notes that this evaluation may be incorporated into the Quality Assessment and Performance Improvement process; CMS solicits comments on making this coordination a requirement. HOME HEALTH AGENCY DISCHARGE PLANNING Current regulations require HHAs to prepare a discharge summary that includes the patient s medical and health status at discharge, include the discharge summary in the patient s clinical record and send the dis- 15

18 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 6 charge summary to the attending physician upon request. Under the proposed rule, HHAs would be required to develop and implement an effective discharge planning process that focuses on preparing patients to be active partners in post-discharge care, provides an effective transition of the patient from HHA to post-hha care and reduces factors leading to preventable readmissions. Discharge planning process The proposed standards for home health discharge planning align closely with those for hospitals. HHAs would be required to: Ensure that the discharge goals, preferences and needs of each patient are identified and result in the development of a discharge plan for each patient. Include regular re-evaluation of patients to identify changes that require modification of the discharge plan, and be updated as indicated. Involve the physician responsible for the home health plan of care in the ongoing process of establishing the discharge plan. Involve the patient and caregiver(s) in the development of the discharge plan and inform them of the final plan. Consider caregiver/support person availability and the patient s or caregiver s capability to perform required care. For patients transferred to another HHA or discharged to a SNF, IRF or LTCH, the HHA would be required to assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF or LTCH data on quality measures and data on resource use measures. CMS would establish a new standard that would require the HHA to send necessary medical information to the receiving facility or health care practitioner, including, at a minimum, the same elements as those specified for hospitals. CMS encourages practitioners to consult with their state prescription drug monitoring program on the associated required medication reconciliation. CMS asks for comment on whether, as part of the reconciliation process, practitioners should be required to consult with their state s prescription drug monitoring program even if the practitioner is not going to prescribe a controlled substance. ANTICIPATED EFFECTS Effects on providers CMS notes that its estimates of the effects of the proposed regulations, summarized below, are subject to significant uncertainty. CMS welcomes comments on its assumptions and estimates. CMS notes that providers may experience significant additional benefits, such as a reduction in patient readmission and other post-discharge complications. CMS also notes the some portion of entities costs will be recovered by other third-party payments, as hospitals periodically revise their charges to private insurance carriers, and that can partially offset cost increases for the approximately half of all patients who are private pay.

19 Summary of Proposed Rule: Discharge Planning Conditions of Participation November 2015 Page 7 Provider Frequency Number Impact ($ millions) Hospitals One-time 4, Annually 107 CAHs One-time 1,328 7 Annually 6 HHAs One-time 11, Annually 283 First year costs 454 Hospitals CMS estimates the effects on hospitals to be about one-hundredth of one percent of total hospital expenditures and revenues. Critical Access Hospitals CMS estimates that the proposed rule would impose costs for CAHs of about $4,600 per hospital, which CMS concludes is a small fraction of 1 percent of revenues. Home Health Agencies CMS notes that the greatest impact would be on HHAs. CMS estimates that this proposed rule would impose costs for HHAs averaging about $24,000 per year, or 1.5 percent of total costs. Effects on patients and Medicare care costs CMS notes that assessing the impact of the proposed rule on patient and medical costs is difficult, given the multiple ongoing initiatives that may affect the same patients and that these changes represent an overlay on existing requirements. However, CMS also notes that decreasing post-discharge mortality morbidity for even a fraction of the 50 million patients discharged annually from hospitals, CAHs and HHAs would provide significant benefit, and that some research has found that transitional care reduces readmissions. CMS welcomes comments that would provide evidence about these findings. To comment CHA encourages that comments on the proposed rule be submitted electronically at At the site, follow the instructions for submitting a comment. CMS must receive comments on the proposed rule by 2 p.m. (PT) on January 4, CMS requests that comments reference the file code CMS-3317-P. For additional information For questions or to provide input for the CHA comment letter, please contact Patricia Blaisdell, CHA vice president, continuum of care, at (916) or pblaisdell@calhospital.org, Alyssa Keefe, CHA vice president, federal regulatory affairs, at (202) or akeefe@calhospital.org, or Debby Rogers, CHA vice president, clinical performance and transformation, at (916) or drogers@calhospital.org. 17

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21 December 10, 2015 TO: FROM: SUBJECT: Case Management Committee Members Pat Blaisdell, VP Continuum of Care Debby Rogers, VP Clinical Performance and Transformation Managed Medi-Cal, Cal Medi-Connect/CCI SUMMARY CHA members have reported several concerns regarding care coordination and access to care for beneficiaries enrolled in managed Medi-Cal (MMP) plans and in Cal MediConnect plans as part of the Coordinated Care Initiative (CCI). ACTION REQUESTED To provide an update and solicit input regarding CHA s work to address issues associated with managed MediCal plans and the CCI. To solicit examples of CCI-related issues to support CHA advocacy. To solicit input from committee members regarding the draft CCI tool kit. DISCUSSION On behalf of members, CHA has submitted to DHCS comments and requests for clarification on several issues, and is in communication with specific plans to address some of these issues. Additionally, during a recent a DC education day, several CHA members and staff met with representatives of the Centers of Medicare and Medicaid Services (CMS), including Tim Engelhardt, CMS Director of the Office of Coordinated Care, to request their assistance. The CMS staff has requested that we provide recent examples of the kinds of problems our members are encountering. CHA is in the process of collecting recent case examples that illustrate our concerns related to care coordination and care access/authorization. CHA is working with Harbage Consulting to develop a resource tool kit and presentation materials for hospital/health system case managers. 19

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23 Cal MediConnect and Hospital Case Managers: Aligning Goals [DATE] [PRESENTER] 1 21

24 Roadmap Authorizations Requesting Timeline Delegation Trouble Shooting Billing Care Coordination Health Risk Assessments Care Coordinators Interdisciplinary Care Teams Individualized Care Plan Admitting a Cal MediConnect Patient Discharging a Cal MediConnect Patient 2

25 Requesting Authorization When requesting authorization for a Cal MediConnect patient, it is important to understand the Cal MediConnect Plan s responsibilities. The plan must: Offer urgent care appointments that require authorization within 96 hours of the request. Cover emergency services without prior authorization. Have a plan in place and follow written policies and procedures for initial and continuing authorizations. Ensure that an authorized care coordinator is available 24 hours a day. Make authorization decisions based on the opinion of a health care professional with clinical expertise in treating the beneficiary s condition. 3 23

26 Authorization Time Frames Authorization decisions must be made within 5 working days from receipt of necessary information to make a decision and within 14 days of the request for a standard authorization (unless granted up to 14 day extension). The decision must be made in 72 hours if the situation is urgent and a delay would jeopardize the patient s life. Concurrent review of authorization for treatment already in place must occur within 5 business days. Retrospective review must occur within 30 calendar days. Authorization for Non FORMULARY Part D pharmaceuticals must occur within 24 hours. The plan may require that you provide sufficient clinical information on the patient with in 24 hours to enable them to make the authorization decision. 4

27 Requesting Authorizations Cal MediConnect Plan Delegates Some Cal MediConnect plans have delegated hospital risk to medical groups or IPAs. Plan delegates are required to follow the same rules as the plans. You should be able to get clear guidance from Cal MediConnect plan provider representatives about how to request authorizations. Ask the delegated plans to share their authorization policies and procedures with you. You can also request that they provide you with training. 5 25

28 Authorizations Trouble Shooting What if I can t figure out who I need to request authorization from? The patient s Cal MediConnect insurance card has all relevant contact information on it. If you cannot access the patient s card, call the plan to request more information. What if I can t get the plan representative on the phone? If the general provider relations department number is insufficient, please see the Cal MediConnect Contact Sheet at calduals.org. To streamline the authorization process for Cal MediConnect patients, you can set up trainings for your staff with provider representatives at each plan in your county. The plans should be able to work with you to clarify their authorization policies and procedures to make the process easier to navigate during patient admission. 6

29 Billing Cal MediConnect Plans One goal of Cal MediConnect was to streamline billing. Providers should be able to submit claims to one plan, rather than navigating both the Medicare and Medi Cal billing processes. Cal MediConnect Plans with Delegated Hospital Risk If the Cal MediConnect plan has delegated hospital risk, you can submit hospital claims to the delegated entity, and they will adjudicate both the Medicare and Medi Cal parts of the claim. How do you know who to bill? You should be able to get clear guidance from Cal MediConnect plan provider representatives about how to submit claims. The patient s Cal MediConnect insurance card includes billing information. In no instance should you bill the patient. 7 27

30 Care Coordination Cal MediConnect is designed to support patients and providers with care coordination. The following resources are available to each Cal MediConnect patient and should be provided by the plan: A Health Risk Assessment (HRA) A Care Coordinator An Interdisciplinary Care Team (ICT) An Individualized Care Plan (ICP) During the patient admission and discharge process, you should be able to contact the patient s Cal MediConnect plan to get more information about these resources, ask to become a member of the ICT, and provide updates on the patient that may impact the ICP. 8

31 Care Coordination: Health Risk Assessments (HRAs) An assessment tool which identifies primary, acute, long term services and supports, and Behavioral Health and functional needs. Serves as a starting point for development of the ICP. Must be completed within 45 days for higher risk beneficiaries and 90 days for lower risk beneficiaries. Reassessments must be conducted at least annually. ICPs must be developed within 30 working days of HRA completion. Through HRA and ICT discussions, beneficiaries will be identified as potentially eligible for LTSS services, including MSSP, CBAS and IHSS. 9 29

32 HRAs & Hospital Patients You can request the HRA from the Cal MediConnect plan to better understand a patient s overall health and functional assessment. If the patient has an HRA, work with the plan to make sure it is updated with the patient s admissions information. It s possible your patient hasn t had an HRA completed, by notifying the plan they have been admitted you can trigger an assessment to help coordinate your patient s care. 10

33 Care Coordination: Care Coordinators Cal MediConnect members should all have access to a dedicated care coordinator. For higher need members, that care coordinator will often be a nurse or social worker who has been following their care over time through the care plan and care team. Cal MediConnect care coordinators should be a resource for hospital case managers. Some Cal MediConnect plans have delegated care coordination a plan representative should be able to direct you to the appropriate care coordinator for your patient. The provider relations representative at the patient s health plan should be your first point of contact. They will direct you to the right person to work with in order to ensure that you are using all of the resources the plan has available to coordinate the patient s care

34 Care Coordination: Interdisciplinary Care Teams A team comprised of the primary care provider and Care Coordinator, and other providers at the discretion of the beneficiary Works with beneficiary to develop, implement, and maintain the ICP. Can include: hospital discharge planner, nursing facility representative, social worker, IHSS provider, CBAS provider, MSSP coordinator, other professionals as appropriate. The plan must offer an ICT for each Enrollee The ICT will be developed around the beneficiary and ensure the integration of the beneficiary s medical, LTSS, and the coordination of Behavioral Health Services when applicable. ICT will facilitate care management, including assessment, This includes: care planning, authorization of services, transitional care issues, coordination with providers to stabilize medical conditions, increasing compliance with care plans, maintaining functional status, and meeting individual beneficiary s care plan goals. 12

35 Interdisciplinary Care Teams & Hospitals Coordinated transitions in and out of the hospital are essential to the patient s overall health. You can work with your patient s Cal MediConnect plan to ensure that the patient s transition experience is coordinated. If a Cal MediConnect member is admitted to your hospital, their hospital providers and case managers should work with the ICT. The member s care coordinator is the point of contact for the ICT. You should contact the care coordinator to review and update the ICT. You do not need the patient s permission to be on the ICT. While the patient is in the hospital, their hospital providers are a critical part of their care team

36 Care Coordination: Individualized Care Plan All Cal MediConnect members should have care plans. They may range from something as basic as the need to get flu shots every year for low risk patients to very complex plans regarding managing chronic conditions and quality of life issues for higher risk patients. As a member of the patient s ICT, you can work with the care coordinator to: Ask to see the patient s ICP to help inform care in the hospital as well as to inform discharge planning; and Request to have the plan updated based on a change in the patient s health status. 14

37 Cal MediConnect: Hospital Admissions 1. Contact the patient s Cal MediConnect plan to: Determine where authorizations and claims should be sent. Identify the patient s care coordinator. You must contact the plan prior to any elective admissions. You must contact the plan within 24 hours of emergency admission. 2. Work with the Cal MediConnect care coordinator to: Learn about the patient s ICP and care goals. Request an HRA or update to the patient s ICP. Connect with the ICT. Begin thinking about possible discharge and transition issues (e.g. work with the plan to identify the LTSS needed to return the patient to community or to identify in network nursing facilities). The sooner you can identify your patient s plan, the sooner you can access the care coordination supports available through Cal MediConnect

38 Cal MediConnect Discharge Planning As case managers, you understand that a successful discharge plan places the patient at the center and makes them and their caretakers full partners in the planning process. Including the patient increases patient safety and improves patient health outcomes. Cal MediConnect should be a resource to you in ensuring that patients experience a safe and coordinated discharge from the hospital back to their community or into a nursing facility. You can partner with your patient s Cal MediConnect plan when they are admitted and at each step in the discharge planning process to ensure a coordinated and patient centered discharge plan. 16

39 Cal MediConnect Discharge Planning Continued Cal MediConnect is designed to help members live in the most appropriate setting. This means Cal MediConnect plans have tools to help move patients out of the hospital and either back into the community or into an appropriate short or long term care facility. You can ask the patient s Cal MediConnect plan and their care coordinator for help to: Work with the patient to identify their goals following discharge. Ensure that the patient has access to all necessary medications and that follow up appointments have been scheduled. Ensure the patient has access to supports and services indicated as necessary by the HRA conducted prior to discharge, including: LTSS, DME, and transportation. (For patients transitioning back into the community upon discharge.) Identify the most appropriate and accessible in network facility to meet the patient s need. (For patients entering a facility upon discharge.) Coordinate the discharge plan as a part of the patient s ICT and ICP

40 In Review... Case management standards and CCI policies are closely aligned. By coordinating with a beneficiary s Cal MediConnect plan, case managers can more effectively navigate care transitions, avoid fragmenting beneficiary care, and utilize the beneficiary s interdisciplinary care team in decision making and discharge planning. Case managers with beneficiary s enrolled in CCI can take the following steps to ensure coordination: Call your patient s Cal MediConnect Plan. Speak with your patient s Care Coordinator and ask about having a role in the beneficiary s Interdisciplinary Care Team. If you are having issues coordinating with the plan, call the Cal MediConnect Ombudsman for assistance. 18

41 Resources 19 39

42 How can I advise my patients? If a patient has a complaint, the first point of contact should be the plan. Plans have internal appeals and grievance procedures. If a patient cannot resolve their complaint with the plan, the next step is to call the Ombudsman: Cal MediConnect Ombudsman: (855) Medi Cal Managed Care Ombudsman: (888)

43 Additional Resources Web Outreach us or complete the online request form 21 41

44 Prepared by: Hilary Haycock, President: Website: 22

45 December 10, 2015 TO: FROM: SUBJECT: Case Management Committee Members Pat Blaisdell, VP Continuum of Care Debby Rogers, VP Clinical Performance and Transformation Preadmission screening resident review (PASSR) SUMMARY CHA is working with the Department of Health Care Services (DHCS) to facilitate the implementation of new procedures and policies associated with requirements for completion of the pre-admission screening and resident review (PASRR). ACTION REQUESTED To provide a status report and solicit input regarding CHA s work associated with DHCS implementation of the required DISCUSSION The purpose of the PASRR is to ensure that individuals with mental illness or intellectual disability receive appropriate services. Completion of PASRR is required for certain individuals prior to admission to a skilled nursing facility. DHCS personnel have shared with CHA staff information regarding the proposed process, including a draft form. CHA has advanced several questions regarding the scope of the evaluation and other issues. 43