Ohio Medicaid Health Homes. The Future for Providers and Patients

Transcription

1 Ohio Medicaid Health Homes The Future for Providers and Patients Understand Prepare Provide 2012 Annual Conference on Aging Ohio Association of Area Agencies on Aging

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3 Making History Medical Reintegration of the Brain/Mind/Body Western Medicine Separation of the Brain/Mind/Emotions (Behavioral Health) from the Body (Physical Health) Behavioral Healthcare IS Healthcare Psychiatrists ARE Physicians Impact on Medical and Diagnostic Stigma Integration Movement (driven by Cost???) Primary Care Staff and Behavioral Health Staff ARE All Healthcare Staff

4 a bit about definitions.. Medical Homes: Practice Model that meets standards to 1) Enhance Access and Continuity of Care; 2) Identify and Manage Patient Populations (Population Health); 3) Plan and Manage (all) Care; 4) Provide Self-Management and Community Support Tools; 5) Track and Coordinate Care; 6) Measure and Improve Performance. The Medical Home is a status achieved by providers/practices and carries recognition by NCQA and accreditation by The Joint Commission. Health Homes: Incentivized Model (CMS Federal Medicaid and/or Medicare) with state flexibility regarding requirements. Model often includes Medical Home requirements. Generally focused on Triple Aim achievement: Improved Quality; Improved Patient Experience; Improved Value (Cost Focus) Ohio Medicaid Health Homes: ODMH/ODJFS/Ohio Office of Healthcare Transformation led effort to implement CMS approved Medicaid Health Homes in Ohio. Entities eligible to become Ohio Health Homes must be certified by ODMH and meet other requirements. THE MODEL IS UNIQUE; OHIO MAY BE THE ONLY STATE TO FIRST INITIATE HEALTH HOMES EXCLUSIVELY IN MENTAL HEALTH ENVIRONMENTS. PRIMARY CARE PROVIDERS (including FQHC S) WILL LIKELY BE THE SECOND WAVE OF IMPLEMENTATION

5 Ohio Health Homes and the Affordable Care Act (ACA) Medicaid Health Home is an option under the the ACA for Medicaid enrollees with chronic conditions, including Mental Health and Substance Use conditions Federal program provides financial incentives for states: - 90% FMAP for health-home related service for first 8 quarters - Incentive grants

6 Federal Health Home Guidance Provider Standards Include: Each patient MUST have a comprehensive care plan Services must be quality-driven, cost effective, culturally appropriate, person and family centered and evidencebased Services must include prevention and health promotion, healthcare, mental health and substance use disorder inclusion, long-term care services as well as linkages to community supports and resources

7 Federal Health Home Guidance Required Services Include: 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, including appropriate follow-up

8 Federal Health Home Guidance Target Populations: Individuals served by a Health Home must have - Two or more chronic health conditions (such as MH or SU condition, asthma, diabetes, heart disease); OR - One chronic condition and at risk for another; OR - One serious and persistent mental health condition NOTE: Regardless of which condition(s) is/are selected, states MUST address MH and SU conditions and consult with SAMHSA on their treatment and prevention

9 Rationale for Integrated Health Homes in Ohio - Affordable Care Act (enhanced payment from CMS = New Revenue) - Escalating Cost of Healthcare in the U.S.A. - Severe Mental Illness as a Cost Driver - Ohio as a Mental Health Leader - Focus on Achievement of Triple Aim - Better Care for Clients/Patients

10 Chronic Medical Conditions 45% of People in the United States have one or more Chronic Conditions Over ½ of these people receive their care from 3 or more physicians often resulting in fragmented care Treating these Chronic Conditions accounts for 75% of direct medical care in the United States Cost Studies suggest that better management of this care could save more than $500B over 10 years

11 25+ Years of Life Lost Suicide and Injury Account for about 30 40% of Excess Mortality 60% of Premature Deaths in Persons with Schizophrenia are due to Preventable (and Costly) Medical Conditions Colton CW, Manderscheid RW. Prev Chronic Dis [serial online] 2006 Apr [date cited]. Available from: URL:

12 Cancer and Injuries People with Mental Illness People with Mental Illness (schizophrenia, bi-polar disorder, major depression) are 2.6 times more likely to develop cancer than the general population (Johns Hopkins Study) Maryland Medicaid Study: Adults with Schizophrenia 4.5 times more likely to develop lung cancer 3.5 times more likely to develop colorectal cancer Almost 3 times more likely to develop breast cancer People with Mental Illness nearly twice as likely to go to Emergency Departments with serious injuries and 4.5 times more likely to die from their injuries

13 Co-morbidity High in Seriously Mentally Ill Skeletal-Connective Tissues Diseases Gastrointestinal Obesity COPD/Chronic Asthma Infectious Diseases Hypertension Dental Disorders Diabetes Cancer Heart Disease Liver Disease

14 20% Percent 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 15% 13% 12% Hypertension 7% 8% Chronic Respiratory Disease Diabetes 5% 10% Arthritis Medicaid with SMI All Medicaid 8% 4% 4% Ischemic Heart Disease 3% Cerebrovascular disease 2%

15 Ohio Medicaid Health Home Client and Provider Eligibility 15 Client Eligibility Adults and children who meet the State of Ohio definition of severe and persistent mental illness (SPMI), which includes adults with serious mental illness and children with serious emotional disturbance, are eligible for health home services in community mental health agencies Provider Eligibility Community Mental Health Agencies (CMHAs) that are certified to provide the Health Home service for individuals with SPMI and meet requirements as set forth in the State Plan Amendment and OAC

16 Health Home Implementation Schedule for SPMI Recommended Implementation Schedule Green Oct 2012 Blue April 2013 Yellow July 2013

17 An Ohio Medicaid Health Home Is: A new service delivery model for Medicaid Consumers that mandates coordination of medical and other care Whole person care coordination: care management for consumers with complex conditions Person-centered care management approach that identifies needed services and supports Planning for needs of the person that does not compartmentalize (fragment) the person s health and wellbeing Providing care and linkages to care that address all of the person s clinical and non-clinical needs

18 Health Home Team Requirements The health home team composition includes BH/PC integration, a multi-disciplinary team approach, quality care and innovation The team composition is flexible and is expected to change as the needs of the clients change overtime; a core team consisting of required members will remain stable in order to maintain consistency and continuity of care The Team will include medical, mental health, substance abuse treatment providers, social workers, nurses and other care providers led by a dedicated care manager who will assure enrollees receive needed medical, behavioral and social services in accordance with a single, integrated plan of care All team members will be responsible for reporting back to the care manager on client status, treatment options, actions taken and outcomes as a result of those interventions.

19 Composition of an Ohio Medicaid Health Home Team Team Leader Care Managers Qualified Health Home Specialists Embedded Primary Care Specialist

20 Health Home Team Composition 20 Health Home Team Leader o Minimum qualifications: o Licensed independent social worker, professional clinical counselor, independent marriage and family therapist, registered nurse with a master of science in nursing, certified nurse practitioner, clinical nurse specialist, psychologist or physician. o Supervisory, clinical and administrative leadership experience. o Health management experience, and competence in practice management, data management, managed care and quality improvement. o Responsibilities: o Provide administrative and clinical leadership and oversight to the health home team, and monitor provision of health home service. o Monitor and facilitate consumer identification and engagement, completion of comprehensive health and risk assessments, development of care plans, scheduling and facilitation of treatment team meetings, provision of health home service, consumer status and response to health coordination and prevention activities, and development, tracking and dissemination of outcomes.

21 Health Home Team Composition 21 Care Manager ominimum qualifications: olicensed social worker, independent social worker, professional counselor, professional clinical counselor, marriage and family therapist, independent marriage and family therapist, registered nurse, certified nurse practitioner, clinical nurse specialist, psychologist or physician. opossess core and specialty competencies and skills in working with persons with SPMI, including assessment and treatment planning. odemonstrate either formal training or a strong knowledge base in chronic physical health issues and physical health needs of persons with SPMI and be able to function as a member of an inter-disciplinary team. oknowledge of community resources and social support services for persons with SPMI. oresponsibilities: oaccountable for overall care management and care coordination, and both provide and coordinate all of the health home service. oresponsible for overall management and coordination of the consumer's care plan, including physical health, behavioral health, and social service needs and goals. oconduct comprehensive assessments and develop care plans. oconduct case reviews on a regular basis.

22 Health Home Team Composition Qualified Health Home Specialist Minimum qualifications: Pharmacist, licensed practical nurse; qualified mental health specialist with a four-year degree, two-year associate degree or commensurate experience; wellness coach; peer support specialist; certified tobacco treatment specialist, health educator or other qualified individual (e.g., community health worker with associate degree). Responsibilities: Assist with care coordination, referral/linkage, follow-up, consumer, family, guardian and/or significant others support and health promotion services. 22

23 Health Home Team Composition 23 Embedded Primary Care Clinician oqualifications: o Primary care physician, internist, family practice physician, pediatrician, gynecologist, obstetrician, certified nurse practitioner with primary care scope of practice, clinical nurse specialist with primary care scope of practice, or physician assistant. o Responsibilities: o Provide health home service including identification of consumers, assessment of service needs, development of care plan and treatment guidelines, and monitor health status and service use. o Provide education and consultation to the health home team and other team members regarding best practices and treatment guidelines in screening and management of physical health conditions as well as engage with, and act as a liaison between, the treating primary care provider and the team. o Meet individually as needed with care managers to review challenging and complex cases. o It is preferred, but not required, that the embedded primary care clinician also functions as the treating primary care clinician and thus may hold dual roles on the health home team.

24 Responsibilities of an Ohio Medicaid Health Home Team

25 Recruitment/Enrollment of Health Home Beneficiaries (Clients) Health Home Expectations -Ensure Capacity to serve all eligible consumers within the designated service area -Determine Eligibility and Enroll ONLY eligible consumers -Develop and educate referral sources about referral processes -Outreach, engagement and education with eligible consumers using consistent communications plan -Orientation for consumer that includes benefits, goals of service and right to decline enrollment Consumer Experience (Group Discussion!! What is expected? What are possible unintended consequences???)

26 Documentation Expectations Comprehensive Health Assessment Medical, behavioral, long-term care and social service needs Reassessment of the client and review of the existing assessment at least every 90 days Updates as needed

27 Documentation Requirements Cont d Single Integrated Care Based on the results of the comprehensive assessment Include clinical and non-clinical service needs Include consumer and family participation Be reviewed at least every 90 days Be updated as needed Be signed by all treatment providers Include health home service components Be shared with all providers Progress Note Based on Medical Necessity Support the monthly health home service claim Include health home services provided by the team

28 Documentation and Submission of Required Demographic and Health Data Health Home Client Demographics Health Home Quality Measures CMS Core Measures AND Ohio Selected Measures

29 Health Home Quality Measures CMS Core Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness State Selected Measures 1. Cholesterol Management for Patients With Cardiovascular Conditions 2. Controlling High Blood Pressure 3. Reconciled Medication List Received by Health Home 4. Comprehensive Diabetes Care: HbA1c level Less Than 7.0% 5. Comprehensive Diabetes Care: LDL-C Screening and LDL-C Less Than 100 mg/dl 6. Use of Appropriate Medications for People with Asthma

30 Health Home Quality Measures- CMS Core Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness continued 30 State Selected Measures 7. Annual Assessment of Body Mass Index, Glycemic Control, and Lipids for People with Schizophrenia Who Were Prescribed Antipsychotic Medications 8. Annual Assessment of Body Mass Index, Glycemic Control, and Lipids for People with Bipolar Disorder Who Were Prescribed Mood Stabilizer Medications 9. Percent of Live Births Weighing Less than 2,500 grams 10. Prenatal and Postpartum Care 11. Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

31 CMS Core Measures 1. Timely Transmission of Transition Record 2. Screening for Clinical Depression and Follow-up Plan 3. Adult BMI Assessment 4. Initiation and Engagement of Alcohol and Other Drug (AOD) Dependence Treatment 5. Ambulatory Care Sensitive Conditions Hospitalization Rate 6. All-Cause Readmissions 7. Follow-Up After Hospitalization for Mental Illness Health Home Quality Measurescontinued 31 State Selected Measures 12. Adolescent Well-Care Visits 13. Adults' Access to Preventive/Ambulatory Health Services 14. Appropriate Treatment for Children with Upper Respiratory Infections 15. Annual Dental Visit 16. Smoking and Tobacco Use Cessation 17. Inpatient and Emergency Department (ED) utilization Rate 18. Client Perception of Care - National Outcome Measure (SPMI Health Home) 19. Proportion of Days Covered of Medication

32 Relationships with Managed Care Providers (Plans) Ohio s Plans Include Amerigroup Buckeye Community Health Plan CareSource Molina Healthcare Paramount United Healthcare Wellcare

33 MCP Relationship Cont d MCPs and Medicaid Health Homes are expected to establish relationships and partnerships with one another Both must develop written policies and procedures that delineate the responsibilities of the Health Home and the MCP in providing services and supports in order to avoid duplication and/or gaps in service Must develop a single point of contact with each other to work on comprehensive assessment and care plan development, participate in health home team meetings, accomplish information and data exchange and assisting the consumer with access to services that may be outside of the scope of the health home provider

34 MCP Relationship Cont d MCP must transmit data, information and reports to the Health Home Teams Included are: MCP Care Management documentation, approved prior authorizations for future services, same day notification of admissions and discharges from an inpatient facility or Emergency Department, clinical patient summaries, grievances or consumer complaints related to the Health Home, ETC. (Health Home is expected to be able to exchange similar data/information with the MCP)

35 Reimbursement Structure Client Enrollment PMPM Per Member Per Month (now termed case rate ) Services Must Meet Medical Necessity Documentation of Services REQUIRED Services Driven by Integrated Treatment Plan Services Must Meet Required Program Goals and Outcomes Health Home Services Replace All CPST Psychiatric Services, Primary Care, Partial Hospitalization, Pharmacy, Counseling (Medicaid Eligible Services) Reimbursed Outside of Per Member Per Month (PMPM) Health Home Structure

36 Let s Discuss CPST Who provides this service NOW? Why are non-cmhc s Providing CPST? Challenges for these Providers if CPST cannot be billed for Medicaid consumers enrolled in Health Homes Become a Health Home? Potential impact on consumers

37 Ohio Medicaid Health Home Program Goals Improve Care Coordination for Clients Improve Integration of Physical and Behavioral Health Care Improve Health Outcomes (all) Lower Rates of Hospital Emergency Dept Utilization Reduce All Hospital Admissions and Readmissions Decrease Reliance on Long-Term Care Facilities Improve the Experience of Care and Quality of Life for the Consumer Reduce Healthcare Costs

38 Discussion Q & A Think about Cost Put yourself in the position of the Health Home Consumer Sustainability What happens if. Other

39 Contact Information Sandy Stephenson Director, Integrated Healthcare, Southeast, Inc