Dual Eligible and High Risk Populations: A Case for Integrated Care and Redesign

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Gavin Shelton
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1 Dual Eligible and High Risk Populations: A Case for Integrated Care and Redesign Peggy Johnson, MD Chief of Psychiatry, Commonwealth Care Alliance Twitter Handle CCABoston May 15, 2014 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

May 15, 2014 DISCLAIMER: The views and opinions expressed in this presentation are

2 Disclosure of Conflicts of Interest Conflicts of interest (COI) There are no conflicts of interest

3 Learning Objectives Understand current dysfunctional fragmented and under resource of care provided to individuals with serious and persistent mental illness Understand the two key care delivery innovations developed at Commonwealth Care Alliance for Dual enrollees. Understand metrics to assess clinical care improvement as a consequence of these innovations.

two key care delivery innovations developed at Commonwealth Care Alliance for Dual

4 Commonwealth Care Alliance (CCA) Commonwealth Care Alliance is a non profit, fully integrated special needs plan contracting with CMS and MassHealth to provide the totality of Medicare/Medicaid benefits to Dual eligible beneficiaries. First demonstration of the ACA s Dual Demonstration Since October 1, 2013, enrolled individuals with Serious Mental Illness meeting Department of Mental Health client eligibility criteria.

5 Care System in need of Redesign and Innovation Primary care is grossly under resourced and poorly designed for those with the greatest need. For many, it is non existent. The more medically and socially complex one is, the more likely one is to be a- drift in a sea of disconnected, unaccountable care providers. Typical health plan based care coordination and management strategies are irrelevant at best, and harmful at worse Psychiatric hospitalizations at a rate of $1100 per day. The only resource available and could be managed in the community

The more medically and socially complex one is, the more likely one is to be a- drift in a sea of disconnected, unaccountable care

6 Innovations PRIMARY CARE MULTIDISCIPLINARY TEAMS with professional and non professional components with abilities to access, manage and coordinate in multiple settings, REPLACES the 20 minute ineffective medically focused physician office visit. INDIVIDUALIZED CARE PLANS, and resource allocations, for long term care, durable medical equipment, and behavioral health services, REPLACES the widespread under resourcing and over resourcing that characterizes rule based benefits management.

7 Innovations (cont'd) Elastic nurse practitioner home response capability, to assess and manage new problems, REPLACES physician telephone management, the Ambulance and the Emergency Department. For those in need of behavioral health (BH) services, INTERGRATED BEHAVIORAL HEALTH CLINICIAN ASSESSMENT, individualized care plan development, implementation and management REPLACES inaccessible BH carve out options or inaccessible services.

For those in need of behavioral health (BH) services, INTERGRATED BEHAVIORAL HEALTH CLINICIAN ASSESSMENT,

8 Innovations (cont'd) 24/7 clinical availability and continuity management REPLACES going it alone. Web based EMR support REPLACES absence of clinical information transfer capabilities. Investment in and the creation of a network of Community Based Crisis Stabilization Units that features clinical integration and continuity with providers More appropriate venues of care for 50-70% of Commonwealth Care Alliance s members with Serious Mental Illness than psychiatric hospitals

Investment in and the creation of a network of Community Based Crisis Stabilization Units that features clinical

9 Measures of Success? Significant reductions in hospitalization admissions and days* Commonwealth Care Alliance risk adjusted hospital admissions and days, are 52% of the Medicare Dual eligible FFS experience ( ) Significant reductions in hospital readmissions CMS NCQA Measure: Commonwealth Care Alliance s 2010-risk adjusted 30 day hospital readmission rate =4% vs. 13% of the Medicare Advantage median, >99 th percentile Significant Reduction in Psychiatric admissions Improved Care Outcomes Reduced mortality *Lewin Associates study commissioned by the SNP Alliance of member risk adjusted hospital utilization experience vs. Medicare benchmark

eligible FFS experience (2009-2012) Significant reductions in hospital readmissions CMS NCQA Measure: Commonwealth Care Alliance s 2010-risk adjusted 30 day

10 Thank You Peggy Johnson, MD Chief of Psychiatry Commonwealth Care Alliance 30 Winter Street Boston, MA x

2014 Model of Care Training SHP_2014838A

2014 Model of Care Training SHP_2014838A 1 Model of Care Training This course is offered to meet the CMS regulatory requirements for Model of Care Training for our Special Needs Plans. It also ensures