State Innovations: Changing the Way Care is Delivered and ...

State Innovations: Changing the Way Care is Delivered and ...

Innovations in Integrated Care for Dually Eligible Beneficiaries June 28, 2016 Michelle Herman Soper Director of Integrated Care, CHCS About the Center for Health Care Strategies A non-profit health policy center dedicated to improving the health of lowincome Americans 2 Current CHCS Projects to Support Integrated Care Project Description

Funder Integrated Care Resource Technical assistance to states pursuing financial alignment demonstrations and other integrated care models Center (ICRC) Centers for Medicare & Medicaid Services (CMS) Promoting Integrated Care for Dual Eligibles (PRIDE) Collaborative of eight integrated health plans to identify and disseminate successful strategies for integrating care for Medicare-Medicaid enrollees The Commonwealth Fund Implementing New Systems of Integration for Dual Eligibles

(INSIDE) Collaborative of fourteen states implementing programs of integrated care and/or MLTSS for group learning and technical assistance The Commonwealth Fund, The SCAN Foundation MLTSS Rate Setting Initiative Collaborative of eight states developing or refining rate setting strategies for MLTSS or Medicare-Medicaid integrated care programs West Health Policy Center Advancing D-SNP-Based Policy Options for Medicare-Medicaid Enrollees

Research and analysis of policy options to promote MedicareMedicaid integration using Dual Eligible Special Needs Plans (DSNPs) DHHS Assistant Secretary for Planning and Evaluation (ASPE) 3 Medicare-Medicaid Enrollees: A Diverse, High-Need Population Navigating Two Systems of Care Population Profile DELIVERY SYSTEM CHALLENGES 10.7 million Medicare-Medicaid enrollees (1 in 5 Medicare enrollees) More likely than Medicare- or Medicaid-only enrollees to have multiple, chronic health conditions More than 40% use LTSS About one-third are under age 65 and qualify due to a disability More than 40% of enrollees under age

65 have a behavioral health disorder Gaps, duplication, fragmentation, and uncoordinated care and systems Institutional bias; not community-oriented or person-centered Cost-shifting between states, the federal government, and different providers; significant potential savings Sources: Medicare-Medicaid Coordination Office. February 2014. Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2013 and Congressional Budget Office. June 2013 . Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies. 4 Federal Vehicle to Advance Medicare-Medicaid Integration

Medicare-Medicaid Coordination Office (MMCO) created at CMS Financial Alignment Initiative Capitated financial alignment demonstrations (CA, IL, MA, MI, NY, OH, RI, SC, TX, VA): Three-way contract: CMS, state, Medicare-Medicaid Plan (MMP) Blended payment, built-in savings Passive enrollment with opt-out provisions and administrative streamlining Managed fee-for-service financial alignment demonstrations (CO, WA): FFS providers Medicaid health homes or accountable care organizations Quality thresholds and savings targets Alternative demonstration (MN) Other states pursing integration through Medicare Advantage Dual Eligible Special Needs Plans 5 Demonstration States ME




OH IN VT AL GA LA FL AK KEY Demonstration states with ACAP MMPs Other demonstration states 6 ACAP Medicare-Medicaid Plans (MMPs)

Of ACAPs 56 member health plans, 14 are MMPs ACAP MMPs enroll close to 30% of all dually eligible individuals participating in capitated model demonstrations State ACAP MMP CalOptima Community Health Group of San Diego Health Plan of San Mateo California Inland Empire Health Plan L.A. Care Santa Clara Family Health Plan

Massachusetts Commonwealth Care Alliance Elderplan/Homefirst GuildNet New York VillageCareMAX VNSNY CHOICE Health Plan CareSource Ohio Rhode Island Neighborhood Health Plan of Rhode Island Virginia Premier Health Plan Virginia Source: Association for Community Affiliated Plans. ACAP Plans and the Duals Demonstrations: Early Progress, Innovations and Challenges. May 2015. Available at: Early%20Progress.pdf 7 Study Methodology and Areas of Focus ACAP commissioned study Goal: To identify innovations advanced under the demonstrations, as well as lessons for integrating care for dually eligible individuals Focus Areas: Supporting individuals in the community and addressing social

determinants of health Coordinating care delivery Identifying unmet needs Engaging providers Coordinating physical and behavioral health Exploring alternative payment models 8 Supporting Individuals in the Community and Addressing Social Determinants of Health Reduce need for institutional care and address social determinants of health Innovative Work with states and community-based Approaches organizations to secure stable housing and housing-related services and supports Manage medical, social, and functional needs of at-risk individuals to maintain them in the community or identify individuals who might be able to transition to community living 9 Example: Care Coordination for Homeless

Populations CalOptima and Inland Empire Health Plan Partner with the Illumination Foundation to address housing instability and ongoing medical oversight for high-need, homeless members Positive impact: MMP partnerships show great promise to improve care for homeless members Illumination Foundation interventions reduced hospital readmissions by 50% and lowered daily cost of care by 90% for homeless individuals in the program Orange County member successfully connected through the Illumination Foundation to a transitional house for veterans. Image used with permission of CalOptima. Source: Illumination Foundation Recuperative Care.

10 Example: Transition to Community Housing Health Plan of San Mateo Community Care Settings Pilot Partnership with care management and housing agencies to help members transition out of institutions to the community Coordinates intensive case management, housing assistance services, and medical care Positive Impact: Transitioned over 70 individuals to community settings as of January 2016

Expects to serve 800 people over the five-year pilot Initial data show high member satisfaction with services, reduced health care service use, and stable community placements Health Plan of San Mateo member successfully transitioned to the community through the Community Care Settings Pilot. Image used with permission of Health Plan of San Mateo. Source: Personal communication with Health Plan of San Mateo staff, January 2016. 11 Improving Care Coordination Improve care management through interdisciplinary care teams Innovative Approaches Enhance discharge/transition planning Implement telehealth solutions Build relationships with community-based

organizations 12 Example: Enhanced Transition Planning VillageCareMAX Assigns members to a transitional care nurse for comprehensive care management on discharge from hospital to community settings Transitional care nurse develops a discharge plan in partnership with hospital staff, community-based providers, and the member 13 Identifying Unmet Needs Resolve unmet needs identified from lack of coordination across Medicare and Medicaid Innovative Create or cover new services and settings for Approaches care

Tailor and redefine existing services 14 Example: Create New Services and Settings Commonwealth Care Alliance Created two crisis stabilization units (CSUs): Accommodate members who need short-term, intensive behavioral health and medical services Residential, therapeutic settings with services provided by care managers and nurse practitioners Positive impact: 86% of individuals in CSUs are inpatient diversions Average length of stay in CSUs is shorter (9.5 days) than the average stay in an inpatient behavioral health unit (11.2 days)

The CSU is a haven of rest amongst the brutality of the streets. CCA Member in CSU Member quote used with permission by Commonwealth Care Alliance. Source: Association for Community Affiliated Plans. ACAP Plans and the Duals Demonstrations: Early Progress, Innovations and Challenges. May 2015. Available at: edownload=true 15 Example: Create New Services and Settings CareSource Member Story Cindys dentures no longer fit correctly after an illness She could not chew properly and had to change her diet

Told she was not eligible for new dentures for several years CareSource care manager collaborated with Cindys medical providers, long-term care providers, and dentist to document the illnesses that led to the problem and submit a new claim 16 Engaging Providers Across the Continuum of Care Obtain provider buy-in and engage several provider types Innovative Approaches Tailor training and outreach strategies to engage different providers Partner with provider associations to provide education 17 Example: Targeted Outreach to Nursing Facilities

CareSource and Community Health Group of San Diego Worked with other MMPs to develop and lead crossplan NF workgroups: Met regularly to discuss operational and programmatic issues Provides MMPs with opportunities to educate providers about the demonstration Positive impact: Created a streamlined process for nursing facilities to find solutions to common issues that could be uniformly addressed across plans 18 Coordinating Behavioral and Physical Health Increase coordination for the many dually eligible beneficiaries with behavioral health conditions Innovative Approaches

Promote interdisciplinary collaboration Develop electronic information sharing and management solutions across PH/BH providers Leverage community connections to provide person-centered, recovery-focused care 19 Example: Developing Electronic Information Sharing L.A. Care Launched an electronic management platform to support PCPs who see individuals with behavioral health conditions PCPs can contact behavioral health specialists via text or email to consult about treatment options or make referrals 20 Example: Leveraging Community Connections to Integrate Physical and Behavioral Health

Virginia Premier Health Plan: Piloting an enhanced care management model to link Community Service Boards (CSBs), that are communitybased behavioral health organizations, to health plan care managers Member Story: Jenny attended CSB therapy sessions, but did not have a PCP The health plan care manager worked with behavioral health care manager to develop a plan of care and set up a PCP appointment The PCP prescribed medication to address Jennys medical issues and ordered appropriate preventive testing The CSB psychiatrist worked with Jennys PCP to adjust her antipsychotic medication 21 Exploring Alternative Payment Models Leverage combined Medicare-Medicaid funding streams to tie payment to value Innovative Link a portion of provider payments to quality Approaches outcomes Establish incentives for PCPs to engage in care coordination for complex patients Use gain-sharing arrangements with providers

22 Example: Tailoring VBP Approaches to Different Providers CareSource Piloting a VBP arrangement with nursing facilities tied to specific demonstration quality measures Working with three contracted NFs to establish performance targets and a payment incentives Building a dashboard to track progress across facilities, including member-level indicators that could be used by case managers 23 Early Lessons Investing in relationships with states and providers before, during, and following program implementation is essential to program success Implementing required care management activities involves significant time and resources from both plans and providers Promoting collaboration and information sharing across primary care and behavioral health providers is critical to achieving physical-behavioral health integration

Simplifying and refining administrative and related processes are key to demonstration success, but this takes time 24 Additional Details and Contact Information Final Report found here: Contact Information: Michelle Herman Soper [email protected] Visit to Download practical resources to improve the quality and costeffectiveness of Medicaid services Subscribe to CHCS e-mail updates to learn about new programs and resources Learn about cutting-edge efforts to improve care for Medicaids highest-need, highest-cost beneficiaries 25

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