building an integrated care team : icos & asaps november 19, 2012 1 mass home care the community...
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Building an Integrated Care Team: ICOs & ASAPs
November 19, 2012
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Mass Home CareThe COMMUNITY LIVING Program
Topics
ASAP Network Readiness to Contract with ICOs – Joan Butler, Executive Director, Minuteman Senior Services
Community Care Linkages – Amy MacNulty, Project Director
The COMMUNITY LIVING Program – Amy MacNulty
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MA ASAPs Ready to Meet ICO LTSS Coordination Requirements
and more…Participation on interdisciplinary primary
care teamRN assessments (CDS) and comprehensive
functional assessmentAvailability to consumers in their home
and across settingsCredentialed and experienced workforce
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As member of ICT, ASAP LTSS Coordinators will be responsible for:
(Sec. 4.6D 2. Care Delivery Model)
Represent the LTSS needs of the Enrollee (a.)
Advocate for the Enrollee (a.) Provide education on LTSS to the
ICT and the Enrollee (a.) Provide LTSS coordination,
including assessments (a.) Evaluate the Enrollee’s Individual
Care Plan and monitor the plan at the Enrollee’s direction (a.)
Participate in initial and ongoing assessments of the health and Functional Status of Enrollees (b.)
Develop the community-based component of an ICP (b.)
Arranging and, with the agreement of the ICT, coordinate the authorization and the provision of appropriate community LTSS and resources (c.)
Assist Enrollees to access PCA Services (d.)
Monitor the appropriate provision and functional outcomes of community LTSS (e.)
Determine community-based alternatives to long-term care (f.)
Assess appropriateness for facility-based LTSS, if indicated (g.)
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If Enrollee has LTSS needs, ASAP LTSS Coordinators will participate
as a full member of the ICT:(Sec. 4.6D 3. & 4. Care Delivery Model)
At any time at the request of the Enrollee with LTSS needs (3.a.) During the initial assessment (3.b.) When the need for community-based LTSS is identified by the Enrollee
or ICT (3.c.) If the Enrollee is receiving targeted case management or rehabilitation
services purchased by DMH (3.d.) In the event of a contemplated admission to a nursing facility,
psychiatric hospital, or other Institution (3.e.) Assist in identifying a more appropriate LTSS Coordinator, if after initial
assessment, it is determined that the Enrollee has specific needs outside the LTSS Coordinator’s expertise (4.)
ASAP LTSS Coordinators will meet qualifications established by ICO, at a minimum:
(Sec. 4.6D 5. Care Delivery Model)
A Bachelor’s degree in Social Work or Human Services, or at least two years working in a human service field with individuals with disabilities (a.)
Completed training that includes education on person-centered planning and person-centered direction (b.) and the independent living philosophy
Experience and expertise in working with people with disabilities and/or elders in need of independent living supports and LTSS (c.)
Knowledge of the home and community-based service system and how to access and arrange for services (d.)
Experience in conducting needs assessments for LTSS needs and with monitoring LTSS delivery (e.)
Cultural Competence and the ability to provide informed advocacy (f.)
Ability to write an Individualized Care Plan and communicate effectively, verbally and in writing, across complicated service and support systems (g.)
Met all requirements of their ASAP employer (h.)
ASAP network has been time-tested, and proven to be deserving of the public trust for the responsibility of operating the Commonwealth’s Home Care Program.
As delegated agents of the Executive Office of Elder Affairs, the ASAPs collectively offer a common suite of Home and Community Based Programs and Services from border to border.
Programs are operated with statewide standards and procedures to ensure consistent quality.
However the governance design also allows for the necessary degree of local customization which is inherent and necessary with the delivery of home and community based services.
MA Executive Office of Elder Affairs
“For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives.” – Secretary Kathleen Sebelius
MA ASAPs History & Mission
Established in 1974 by state law to create community alternative to nursing home care for low income MA residents 60+ who needed assistance with ADLs (coordinate services on behalf of Medicaid eligible members 60+, Chapter 19A,4B)
Unique statewide infrastructure for home and community based care with 40 years experience serving people with chronic care needs and their caregivers over the long term
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MA ASAP History & Mission Con’t
Functional orientation to independent living in the community over the long termo In MA – home care (certified) and home care (ADL assistance) o Embrace consumer choice and empowermento Well positioned to assist consumers to integrate healthy lifestyle and
compliance with medical instructions into daily living Largest conduit of state and federal funding for long term
services and supports delivered to local communities Evolved as single entry point to wide range of in home and
community based options and supports for broad population of seniors, disabled adults and caregivers
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Who are the MA ASAPs?
27 Not for Profit organizations who are members of Mass Home Care
Statewide network that covers every city and town Located in communities served Members of community on Board of Directors Specialize in assessment and care coordination &
SNF Diversions and managing a vendor network Standardized assessment tool and client data
system
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FY11 ASAP Spending ~$340m
On Behalf of MA Executive Office of Elder Affairs
2011 People Served Statewide
55,800 Clinical Assessment & Evaluation
66,200 Home Care/Respite Care, Enhanced Community Options & CM, Community Choices & CM
18,282 Protective Services reports
ASAP Programs & ServicesEvidence Based
ProgramsCare Transitions ( Coleman Model ) Patient Centered Interdisciplinary Addresses continuity of care across
settings and practitioners Uses Personal Health Record Teaches Self Management Healthy Living Programs Chronic Disease Self Management
(Stanford Program)o Diabetes Self Managemento Arthritiso Chronic Pain Management 2013
Mental Health and Depression Matter of Balance Fall Prevention Healthy Eating Power Tools for Caregivers
Home assessments of a person's functional ADL's & IADL'so Cognition, Depression and Nutritional
Screeningo Home Safety Assessment o Advance Directives
Caregiver supports Authorize, purchase and monitor home &
community-based services (extensive vendor network)
Medication management assistance Nursing Home Pre-Admission Screenings Counseling on Community Options Money Management Elder Abuse & Neglect Investigations and
Intervention Referrals to wellness/disease prevention
resources
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Community-Based Supports
Model of Home CareIndependent Care Management Plus
Vendor Network* with 1,400 contracts statewide
Personal Care Assistance Homemaking & Home Chores Laundry & Grocery Shopping Home Health Services-Skilled RN,
OT, PT, Speech Therapy Supportive Home Care Aide Adult Day Health Care Alzheimers Day Programs Habilitation Therapy Safe Return Wander Locator
Meals on Wheels Transportation Personal Emergency Response Medication Dispensing System Adaptive Housing/Assistive
Technology Short term residential respite in
Nursing Facility, Assisted Living In Home Respite Mental Health
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* Vetted and monitored for compliance and quality* Vetted and monitored for compliance and quality
ASAPs offers information and referral for consumer education & access to
local and statewide services
Public benefits, food stamps/fuel assistanceo SHINE
Private Pay services Housing options Transportation Groceries/Pharmacies that
deliver Senior Dining Senior Centers/COAs Support Groups Employment
Nursing Home Ombudsman Assistive Technology Assisted Living Facilities Nursing Facilities Elder Law Attorneys Driving resources Disease specific resources:
Alzheimers, MS, ALS, Parkinsons Fact Sheets/Seminars Life long learning LGBT resources
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ASAP Consumers Served Annually Over 100,000 calls for Information and Referral
69,000 seniors received Care Management & in home and community based services (14,500 were nursing home level of care)
75,000 received Meals on Wheels or community nutrition services
50,000 Nursing home screenings to assess potential for return to the community and transition assistance
24,000 SCO members served by ASAP GSSCs
550+ consumers received Options Counseling services
Serving adults of all ages with disabilities and their caregivers
Since the 1980s, ASAPs have coordinated MassHealth services that serve adults with disabilities.
14 of the ASAPs are Personal Care Management Agencies (PCMs)
10 of the ASAPs manage Adult Foster Care programs
12 of the ASAPs manage Group Adult Foster Care (GAFC)
Founding partners of MA Aging and Disability Collaborations (ADRCs)
ASAP Workforce Capacity & Expertise
Care Coordinators/Care Managers (944) RNs (265) RN Supervisors (39) Total Employees (3,351) ASAP staff are culturally and linguistically diverse to match the
needs of the community (ASAP Case Staff speak 55 languages and translators available in all areas)
Expertise in services for elders and adults with disabilities and chronic conditions
Experience and expertise in person-centered care, consumer engagement and the independent living philosophy
Experience in managing a capitated system for a fee for service network
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ASAPs Alternative to Nursing Homes
Staying Home: (ECOP/Choices)ASAPs manage programs targeted at people who meet the clinical criteria for the nursing home level of care.
10,248 elders per month are not in nursing homes in MA today because of ASAP services
Results: $266 million annual savings
Returning Home: (CSSM)ASAP staff visit nursing homes to screen elders on a pre-admission and post-admission basis
to determine their ability to return home to design a care plan to transition to home to avoid NF placement at the beginning
Money Follows the Person Initiative
Between July 12, 2011 and June 30, 2012, 168 people have been transitioned out of nursing homes. Another 86 people are enrolled in the program but have not yet been placed.
Of those 168 placements, 125 (74.4%) were elders placed by ASAPs.
19 (11.3%) were DD/ID, 22 (13.1%) were physically disabled, and 2 (1.1%) were MH clients.
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SCOs & ASAPs: Template for ICOs
Geriatric Support Service Coordinators are members of the primary care team who:
may assess all enrollees upon enrollment coordinate community support services with the agreement of
primary care team coordinate non-covered services (housing, home-delivered
meals and transportation) monitor outcomes & track enrollee transfer review enrollee care plans
ASAPs currently manage Vendor Network for 3 SCOs : Long term services and supports
2+ years of Collaboration & Partnering in response to Health Reform Initiatives oCCTP/Section 3026oPioneer ACOsoPCMHs/Physician Practiceso Self Management Supports/CDSMPo ICOs
The COMMUNITY LIVING Program22
Community Care Linkages SM
A Division of Mass Home Care
Community Care Linkages is a strategic initiative to effectively integrate services of the Massachusetts Aging Services Access Points (ASAPs) into the evolving healthcare delivery system.
CMS Payment to MA ASAPs for Care Transition Services at part of CCTP
1. Elder Services of Berkshire County Berkshire Medical Center and
the Berkshire Visiting Nurse Association
2. Elder Services of Worcester & BayPath Elder Services MetroWest Medical Center; St.
Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital
3. Somerville-Cambridge Elder Services & Mystic Valley Elder Services Cambridge Health Alliance and
Hallmark Health System
4. Merrimack Valley of Massachusetts and Southern New Hampshire Elder Services Anna Jacques Hospital, Saints
Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital 24
http://innovation.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html
47 partners announced in three rounds, 4 in Massachusetts
The COMMUNITY LIVING Program
The Community Living Program is offered exclusively through Mass Home Care and offers beneficiaries of ICOs, ACOs, PCMCHs, and other care provider organizations access to a wide range of vetted home and community based supports, including care coordination, member education and engagement, and registered nurse assessments.
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Statewide network of ASAPs are aligning with local and national trends towards integrating aging and disability services.
Statewide network of ASAPs are aligning with local and national trends towards integrating aging and disability services.
Member-Centered Long Term Services for Dual Eligibles:Statewide networkSuccessful partnering with community agencies and medical providers
o ILCs, ADRCs, SCOs, ACOs, PCMHs, FQHCs
Key Serviceso Initial Assessmento Basic Coordinationo Complex Care Coordinationo RN Assessmentso Network Managemento Evidenced-Based Healthy Living Programso Care Transitions Coaching
A Mass Home Care Initiative for Integrated Care Organizations
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The COMMUNITY LIVING Program for ICOs*
Putting the pieces together
*Refer to handout for narrative
LTSS Coordinator
Initial Assessmento In-person, comprehensive initial assessment (CDS/MDS-HC)o Assess functional status (ADLs)o Determine formal and informal supports
Care Coordinationo Conduct Comprehensive Person-Centered Assessmento Develop Care Plan o Engage Informal Supportso Assess Risk and Care Team Managemento Coordinate Services Across Care Continuumo Assist with Nutritional Plan of Careo Care Transitions Coaching
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ASAP RN Assessments
Experience with initial and on-going assessments (CDS/MDS-HC)
Conduct assessment and plan of care for personal care (non-PCA)
Complete PCA evaluations
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Network Management
30+ years experience with successful management of vendor networkoEmploy standard statewide protocols for
contracting, monitoring, quality, compliance
Respond to ICO needs to develop/expand services and programs
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Evidence Based Health Living Programs
Chronic Disease Self Management (Stanford Program)oDiabetes Self ManagementoArthritisoChronic Pain Management 2013
Mental Health and Depression Matter of Balance Fall Prevention Healthy Eating Power Tools for Caregivers
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What ASAPs can offer your members:
LTSS Coordinationo Initial Assessment (CDS/MDS-HC)o Basic Coordinationo Complex Care Coordination
RN Assessments Network Management Nursing Home Screening Evidenced-Based Healthy
Living Programs Care Transitions Coaching Caregiver supports
Authorize, purchase and monitor home & community-based services (extensive vendor network)
Medication management assistance Counseling on Community Options Money Management Elder Abuse & Neglect
Investigations and Intervention
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