San Diego LongTerm Care Integration Project: Resetting the Context - PowerPoint PPT Presentation

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San Diego LongTerm Care Integration Project: Resetting the Context

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Can we create a new way to pay for long-term care? Can we integrate acute and long-term care? ... WPP members are in nursing homes compared to 26% of Medicaid ... – PowerPoint PPT presentation

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Title: San Diego LongTerm Care Integration Project: Resetting the Context


1
San Diego Long-Term Care Integration Project
Resetting the Context Mark R. Meiners Ph.D.
National Program Director Robert Wood Johnson
Foundation Medicare/Medicaid Integration
Program Planning Committee Meeting March 8,
2006
2
  • Why the Interest in Long-Term Care?
  • Fascinating array of services we fear (nursing
    home) and favor (home and community-based
    services)
  • Often preceded by medical conditions served by
    primary and acute care
  • It is very expensive yet 80 is provided by
    family and friends.
  • Medicaid is a significant payer
  • Often a catastrophic expense for individuals.

3
  • Why the Interest in Long-Term
  • Care (LTC) Reform?
  • People are living longer.
  • Need for LTC increases with age
  • ages 65-59 5.7
  • ages 85-69 39.8
  • ages 95 72.1
  • Baby boom population coming of age.
  • LTC reform options exist/have been tested.

4
Economics of Aging Health
  • Can we create a new way to pay for long-term
    care?
  • Can we integrate acute and long-term care?
  • Can we encourage informal care?
  • Can we give disabled persons maximum control over
    the services they receive?
  • Long-Term Care Insurance Partnership
  • Medicare/Medicaid Integration Program
  • Service Credit Banking in MCOs
  • Independent Choices Cash and Counseling

5
Background to Medicare/Medicaid Integration
Program Experiences Robert Wood Johnson
Foundation 15 Participating States CO, FL, MN,
NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI,
VT For Background and Technical Assistance
Documents see http//www.gmu.edu/departments/chpr
e/research/MMIP/index.html
6
  • Key Dimensions of Integrated Care Program
    Development
  • Scope and flexibility of benefits - more than
    fee-for-service
  • Delivery system - broad, far reaching, options,
    experienced
  • Care integration - care teams, central records,
    care coordination.
  • Program administration - enroll, dis-enroll,
    integrated data IS
  • Quality management and accountability - unified,
    broad, CQI
  • Financing and payment - flexible, aligned
    incentives

7
  • Wisconsin Partnership Program (WPP)
  • Wisconsin Family Care

8
  • Wisconsin Partnership Program (WPP)
  • Integrates all Medicaid with Medicare benefits
    through non-profit health plans that blend
    capitation payments from both these programs.
  • Relies on a broad interdisciplinary team that
    includes the patient and their physician, along
    with a nurse practitioner, nurse, social worker,
    and others as needed.

9
Family Care
  • County based program provided capitation payment
    to provide managed long-term care with primary
    and acute services carved out and coordinate on a
    fee-for-service basis.
  • Limits its integration efforts to Medicaid-only
    services that fall under its capitation payments.
  • Relies on nurses and social workers to
    coordinate with primary and acute care services
    (physician, hospital, prescription drug, dental
    care, podiatry, vision, and mental health related
    services), but does not provide those services.

10
  • WPP Evaluation Results
  • The number of inpatient hospital days decreased
    52 for physically disabled members in the first
    year after enrollment in WPP.
  • The number of nursing home days decreased 25
    for elderly in the first year after enrollment in
    WPP. Only about 6 of WPP members are in nursing
    homes compared to 26 of Medicaid recipients age
    65 across the state.
  • By close coordination and monitoring, the WPP
    has been able to keep prescription drug increases
    in the range of 9 to12, well below the national
    average of 18 to 21.
  • The vast majority (95) rated the services
    excellent or very good. Only 5 of members
    disenrolled for reasons other than death or
    relocation.

11
Wisconsin Partnership Program Outcomes
12
Wisconsin Partnership Program Outcomes
13
  • Family Care Evaluation Results
  • Family Care has also recently undergone a
    rigorous independent review conducted by APS
    Healthcare (APS, 2005). The study focused on the
    fourth (2003) and fifth (2004) years of
    operation.
  • Evaluators examined Family Care members health
    status, health care costs, and long-term care
    costs compared to similar individuals receiving
    fee-for-service Medicaid services in the rest of
    the state.

14
  • Family Care Evaluation Results
  • Waiting list elimination--a key selling point of
    Family Care--has been achieved for over three
    years now.
  • Over the two-year study period, average
    individual monthly Medicaid costs for Family Care
    members outside Milwaukee were 452 lower than
    costs for their comparison group. Costs for
    members in Milwaukee were 55 lower than those
    for their comparison group.
  • Source of savings (1) a direct effect of a more
    cost-effective mix of service purchases and (2)
    an indirect effect of improving members health
    and ability to function independently.

15
  • Family Care Evaluation Results
  • Family Care members visit their primary care
    physician more regularly than the comparison
    group. This benefit accrued across all counties
    and target groups.
  • This additional attention to primary health care
    is thought to be related to the work of the
    Family Care nurse care managers.
  • More frequent primary care physician visits
    appeared to provide opportunities to increase
    prevention and early intervention health care
    services that, in turn, reduced the need for more
    acute and costly services.

16
San Diego Stakeholder LTCIP Vision for Elderly
Disabled
  • Develop system that
  • Is consumer driven and responsive
  • Provides continuum of health, social and support
    services that wrap around consumer w/prevention
    early intervention focus
  • Pools associated (categorical) funding
  • Expands access to/options for care
  • Utilizes existing providers

17
Stakeholder Vision (continued)
  • Fairly compensates all providers w/rate structure
    developed locally
  • Engages MD as pivotal team member
  • Decreases fragmentation/duplication w/single
    point of entry, single plan of care
  • Improves quality is budget neutral
  • Implements Olmstead Decision locally
  • Maximizes value of federal and state funding

18
Where are we now?
  • BOS come back with 3 options
  • Network of Care
  • Physician Strategy
  • Healthy San Diego Plus (HSD)
  • LTCIP/HSD Options
  • 1 3 year pilot w/ limited IHSS enrollment
  • 2 - Governors Proposal/Access Plus

19
Network of Care/Aging and Disability Resource
Center (ADRC)
  • Test/improve existing web-based system expand
    to support 2 service delivery models
  • Funding AoA, 610,000 over 3 years for Aging
    Disability Resource Center
  • Expand as communication link btw MD, consumer,
    caregiver, community providers
  • Develop CQI program/Community Education Workgroup
  • www.sandiego.networkofcare.org

20
Physician Strategy
  • Fee-for-service initiative to improve chronic
    care management
  • Partner w/physicians vested in chronic care
  • Develop interest/incentive for support of HCBC
  • Train on healthy aging, geriatric/chronic disease
    protocol, pharmacy, HCBC supports
  • On-going meetings with physicians
  • Implementation plan in development

21
  • Key Micro Strategy Primary Care Teamwork
  • Focus on holistic approach encompassing health
    and welfare (e.g., psychosocial, economic,
    environmental, social supports)
  • Monitor ongoing health status for early
    detection of problems
  • Emphasize health education and prevention
  • Support chronic care self management
  • Increase opportunities for communication

22
  • Summary Thoughts
  • ALTCI demonstrations are learning opportunities
    for better care systems
  • Best model not clear.
  • New Medicare Special Needs Plan rules represent
    new opportunity and challenge.
  • Quality improvement evaluation is necessary
    going forward.

23
LTCIP Options
Option 1- pilot w/ up to 1000 IHSS clients/year
Option 2-Governors Proposal (Access Plus)
  • Main Features
  • Voluntary 3 year pilot
  • For Medi-Cal-only dully eligible Aged, Blind
    and Disabled (ABD). Limited to 1000 IHSS
    clients/yr. Enrollment not capped for non-IHSS
    Medi-Cal ABDs
  • Local share (realignment ) for IHSS direct
    service hours continues to be sent to State IHSS
    admin unaffected during pilot.
  • If IHSS client chooses to enroll in LTCIP, will
    request a voluntary discontinuance from IHSS, but
    continue to be tracked and providers paid thru
    CMIPS
  • Independent evaluation
  • Main Features
  • Voluntary 5 year pilot
  • For dual ABDs only
  • LTCIP and IHSS will be mutually exclusive.
  • If IHSS client opts to request voluntary
    discontinuance and enroll in LTCIP, personal care
    services will be provided under the health plan
    cap with no funding from IHSS or realignment
  • Independent Evaluation

24
How to influence planning?
  • Get on LTCIP mailing list for updates
  • Log onto website for background info
    www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/
  • Call or e-mail input/ideas 858-495-5428 or
    evalyn.greb_at_sdcounty.ca.gov or 858-694-3252 or
    sara.barnett_at_sdcounty.ca.gov
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