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Moving Forward: The Changing Landscape of Case Management
Meghan Shineman
NYC Department for the Aging (DFTA)
Aging Concerns Unite Us (ACUU) 2019 Conference: Workshop E3 -- Moving Forward: The Changing Landscape of Case Management
About DFTA
New York City Department for the Aging (DFTA):
DFTA is one AAA that serves the five counties of NYC
Approximately 1.5 million people 60+ years old live in NYC
DFTA reaches about 230,000 seniors, caregivers, and others through its programs
DFTA contracts with a network of over 400 contracted CBOs
DFTA Programs with Case Management/Assistance
Case Management Agencies (CMA) o 21 geographically-based CMAs serve about
22,000 seniors annually
o CMAs assess eligibility and turn on Home Care and Home Delivered Meals (HDM). 3,000 seniors receive home care from 5
providers
18,000 seniors receive HDM from 23 providers
Caregiver Programs 7 geographic and 3 special population programs serve
about 11,000 caregivers
Senior Centers 249 centers attract 28,000 people/day
NORCs 28 NORCs serve about 11,000 clients
Elder Abuse Prevention and Intervention One office in each of the 5 boroughs; DFTA houses a
resource center
Additional DFTA Services
Health Insurance Information, Counseling and Assistance Program (HIICAP)
Thrive NYC o Friendly Visiting Program
oGeriatric Mental Health Initiative
Grandparent Resource Center/ Foster Grandparent Program
Senior Employment
Bill Payer Program
Assigned Counsel Project
Safety Monitoring Resources
Transportation
Social Adult Day Care
NY Connects One office in each of the 5 boroughs
Other DFTA Initiatives
Care Transitions through DSRIP – more formal relationship with NYC’s public hospital system (H+H)
CommunityCare Link (CCL) oNetwork model offering back-office
admin services to help bridge the aging & health sectors in NYC
DFTA Case Management
Assessments are conducted to identify strengths and needs of older adults, and arrange/coordinate services such as:
Assessment & referrals to community resources
Financial screening for benefits & entitlements
Gatekeeper to DFTA-funded services (HDMs, home care, elder abuse, friendly-visiting, bill payer, and mental health)
Assistance & counseling on non-DFTA services (i.e. long-term care, respite, and housing options)
COMPASS Assessment
Health-specific elements
Other elements
• Health status: insurance, provider info
• Medical history • Recent healthcare
events • Use of assistive
devices • Screens for
depression, alcohol, and nutrition
• Psycho-social status • Medications • ADL/IADL needs
• Client demographic & contact Info
• Housing status & home safety checklist
• Service & benefit eligibility and receipt
• Informal support status
• Monthly income • Legal info/advance
care planning (optional)
DFTA COMPASS Supplemental
Supplemental screens for:
1) Physical health issues (i.e. falls, oral health)
2) Cognitive/Mental health issues
3) Family/Informal caregiver support
4) Housing issues
5) Elder abuse/neglect issues
6) Eligibility for home-delivered meals
Future Focus of DFTA Case Management
DFTA has been enriching case management, including screening and connections to:
• Oral care
• Mental health
• Vision & hearing
• Falls prevention
Home Meds pilot = expanded in 2019
Health Benefits of Case Management
Impact on client’s health & wellbeing:
Assist clients in accessing appropriate services, benefits, and entitlements needed to age safely at home and maintain their quality of life
Coordination to social services (social determinants of health)
Reduces social isolation among largely homebound clients
Eases caregiver burden
How can integration with health care benefit CMAs?
Better coordination of care across all programs makes for a better client/patient experience
Access to RHIOs/SHIN-NY can provide more timely health information about clients, including hospitalizations
Paid relationships offer more sustainability and capacity to decrease wait lists
Lessons Learned from Health Partnerships
Different organizations cultures and requirements (e.g. onboarding personnel procedures, compliance rules)
Different patient tracking IT systems = duplication of effort & inconsistent information
Value proposition or Proof of concept
True integration with healthcare will yield more appropriate and sufficient number of referrals as well as more targeted and effective interventions
What Does the Future Hold?
Value-based Payment resulting from DSRIP (for Medicaid/MLTC health plans)
Chronic Care Act / Medicare Advantage Supplemental Benefits
Increased presence of SDH screenings and electronic (closed-loop) referral systems
Improving Health Outcomes by Addressing the Social Determinants of Health
June 12, 2019
2019 Aging Concerns Unite Us
Denard Cummings, Director
Bureau of Social Determinants of Health
June 2018
Bureau of Social Determinants of Health
June 2018
Bureau of Social Determinants of Health
History
BSDH established in January 2018 (formerly
BSH) to implement the VBP Roadmap
requirement regarding Social Determinants
of Health and Community Based
Organizations
Purpose
Transform the New York State Healthcare
delivery system by integrating health and
human services. Addressing the Social
Determinants of Health to improve the
quality of care and health outcomes for NYS
most vulnerable populations.
Health Systems
Data
Medicaid Reform
Health Outcomes
Community Based
Organizations
BSD
H
June 2018
What are Social Determinants of Health?
June 2018
Social Determinants of Health
June 2018
The 5 Domains of Social Determinants of Health
June 2018
Factors Correlated with Health Outcomes
Determinants of Health. (n.d.). Retrieved from https://www.goinvo.com/features/determinants-of-health/
June 2018
Healthcare Spending in the US
June 2018
Health Care Spending in US & Other Countries
June 2018
Health Care and Social/SDH Spending
June 2018
Health Care Quality, Health Care Spending, and Social/SDH Spending
June 2018
Changing the Healthcare Delivery Conversation
June 2018
Case Study
Philip’s Story
• Homeless
• Food Insecure
• Crime History
• Chronic Comorbid Conditions
• History of Substance Abuse
• Cognitive Limitations
• No Informal Support System
• 160 Emergency Room Visits one year prior to intervention
June 2018
Case Study – Philip’s Story
• Health Home Enrollment (Coordination of Care)
• Supportive Housing Intervention
• Nutrition Intervention
• Reduction in Law Enforcement Interactions
• Reduction in Emergency Room utilization from 160 visits annually to 20 visits the year following the intervention
June 2018
Housing Security: Outcomes of MRT Supportive Housing
Housing is Healthcare!
Number of high-need Medicaid recipients served to date: 12,000+
June 2018
Food Security: Food is Medicine
• Low-cost/High-impact intervention: Feed someone for half a year by saving one night in a hospital
• Reduce overall healthcare costs by up to 28% (all diagnoses compared to similar patients not on MTM)
• Reduce hospitalizations by up to 50% (all diagnoses compared to similar patients not on MTM)
• Reduce emergency room visits by up to 58% (pre-post MTM intervention)
• Increase the likelihood that patients receiving meals will be discharged to their home, rather than a long term facility (23%) (all diagnoses compared to similar patients not on MTM)
• Increase medication adherence by 50% (pre-post MTM intervention)
God’s Love We Deliver – Medically
Tailored Meals
http://www.glwd.org
June 2018
NYS Value Base Payment Roadmap
June 2018
Value-Base Payment Arrangements
• DOH has approved 74 SDH interventions and CBO contracts
• Approved CBO contracts reflect both direct contracting with MCOs and sub-contracting with VBP providers (i.e. hospital, IPA, ACO)
• CBO contract outlines: • scope of intervention
• success metrics
• date sharing agreement
• reporting requirements
• Most CBO contracts are structured as payment for services rendered
June 2018
Advancing Care with CBO in VBP
Experience addressing social determinants of
health and navigating local community
Follow up with patients
Find and engage disengaged patients
Provide non-medical services that address
barriers to improved patient health outcomes
Overcome cultural competencies, geographical
and language barriers
Report back outcomes and ensure patient
centered care
June 2018
For Additional Information:
https://www.health.ny.gov/mrt/sdh
Contact Us:
Bureau of Social Determinants of Health
Thank you!
Dr. Mary Ann Spanos OFA/AAA Director
Chautauqua County, New York
Growing Aging Population
Traditional Funding (AOA & State) ◦ Stagnant or not stable
◦ Funding not adequate for need
◦ Out of our control
Developing new funding sources ◦ Stable revenue source
◦ More control
◦ Growth depends on you!
2011 2018
Set a price and sell your services to: Private pay Medicaid LTC plans Doctors Hospitals
Services Dietician Services EBI Programs Home Care Home
Repairs/Access Home Delivered
Meals PERS Social Adult Day Transportation
Combine forces with subcontractors
Can grow staff as business increases
Little Risk/Liability ◦ Doing the same work for a new set of payers
New Revenue & Profit ◦ Profit sharing with subcontractors
◦ Reduce wait list for services
◦ Expand services to more seniors
◦ Revenue reinvested to meet rising demand
Contract Development (Legal & Finance team)
Referral Procedures (Fax, e-mail, Peer Place)
HIPAA Compliance Billing
◦ Forms & how to complete ◦ Electronic portal & clearing house
Credentials ◦ NPI (National Provider Identification) Number ◦ W9 Form for the County ◦ County Tax ID number ◦ Insurance/Liability coverage
Miscellaneous (Vendor Data Form) ◦ ADA checklist (any building where services occur) ◦ Policy & Procedures ◦ Proof Program Standards/oversight ◦ Client Bill of Rights ◦ Monitoring
Low Risk ◦ Paid for quantity ◦ Only get paid for what you produce
◦ Volume unknown but usually grows over time
Pricing ◦ Time to evaluate full cost ◦ Ensure OAA not subsidizing ◦ Renegotiate if needed-Build in profit
Process & Procedures ◦ Grow slowly ◦ Develop work flow of referrals ◦ Billing procedures : Paper vs Electronic ◦ Monitor & adjust
Payers & Population Goal based payment
Payers
◦ Medicare/Medicaid
◦ Medicare Advantage
◦ Private Insurance Plans
Population
◦ Everyone in a particular area
◦ All Diabetics (any age)
◦ High utilizers (any age)
Paid for outcomes
◦ 50% of “no shows” to MD
◦ 80% screened for falls risk
◦ Quality vs Quantity
Package of Services based on:
◦ Needs of the payer (HEDIS)
◦ Reducing cost High needs clients
◦ Connecting with non-utilizers Paid for Value/Quality
◦ How you reduce payers costs
◦ Ability to get clients to engaged
◦ Get clients to PCP instead of ER
◦ Avoid Hospitalization
◦ Improve HEDIS measures Payment may involve Risk
◦ Pay for Performance.
◦ Only paid if quality metrics are met. (I.E. Decrease ER usage)
Reduce Costs: Short-term Preventative: Long-term
Connect to regular care
Stop high use of ER
Prevent avoidable admissions
Focused on…
Meeting clients where they live
Patient activation
◦ values & goals
Non-medical barriers
◦ Social/environment
◦ Economic/housing
◦ Transportation
Teach self-management Longer-term education ◦ Evidence based
◦ Older learner-focused
Screen for risk & address Connect to resources Exercise programs ◦ Evidenced-based
OFA Case Management Options Counseling
Differs from Medical CM
Person Centered Assessm.
Community Care Focus
Assess Client’s abilities
Social supports or lack
Deploy network of community care options
Regular follow-up to address emerging needs
Long-term relationship
Assess client’s needs & goals Person-center planning Eval. social supports Connect & deploy resources Provide follow up Coaching in self-management
Current Case Management Future Case Management
Working with 60+
Annual Assessment ◦ 2 Month follow-up
Options counseling ◦ Periodic Follow up
Person Centered Plans
Care Coordination Any Age Care Transitions
Intervention ( CTI) with 30, 60, 90 day follow up
Options counseling with monthly f/u & transport assist
Fall prevention Package screen, in-home assessment & f/u classes.
Medication Compliance (In-
home medication review, Pharmacist review for interactions
