san diego long term care integration project april 14, 2004 ltcip planning committee meeting
TRANSCRIPT
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San Diego Long Term Care Integration Project
April 14, 2004
LTCIP Planning Committee Meeting
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Announcements Aging Summit: April 19, 2004, 7:30-
3:30, San Diego Concourse Next Planning Committee Meeting: May
4, 2004, 10:30-noon, County of SD, 8965 Balboa Ave, Conference room (1st floor)– Community Education Kick-off– Chair: Betty London
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Community Planning Process
From 50 to 600+ key stakeholders over past 5 years: 12,000+ hours
Seeking to improve system of care for consumers and providers
Planning within state LTCIP authorization (form follows funding)
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San Diego County Board of Supervisors&
State Office of Long Term Care
Jean Shepard, Acting DirectorCounty of San Diego, Health & Human Services
Agency, (HHSA)
Advisory Group:Goal: Make final decisions and
recommendations for inclusion in the plan.
Planning Committee:Goal: Guide the LTCIP planning process.
Suspended Workgroups pending service delivery
model decision
Suspended Workgroups pending service delivery
model decisionHealth Plan Partners
Workgroup
Health Plan Partners Workgroup Finance/Data
Workgroup
Finance/DataWorkgroup Options Workgroup
Options Workgroup
Internet• Facilitates
communication• Provides broad public
education
Pamela B. Smith, Project DirectorEvalyn Greb, Project ManagerAging & Independence Services
Lead County Agency
MH & SAWorkgroup
MH & SAWorkgroup
Explore use of the Healthy SanDiego model for potentialService delivery system for LTCIP.
Determine the financialfeasibility of the proposedLTCIP for San Diego County.
Make recommendation to Planning Committee re: inclusion of mentalhealth and substance abuse services in LTCIP.
Incremental LTCI Strategies:1) Network of Care2) Physician Strategy3) Health Plan Pilots
Governance-Case Management-Info/Technology-Quality Assurance-Scope of Services-Workforce Issues-Community Network Development-Developmental Disabilities
Community EducationWorkgroup
Community EducationWorkgroup
Explore use of public health education models that promote improved chronic care management for LTCIP
Long Term Care Integration Project
Organizational Chart & Decision Tree
April 2004
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San Diego Stakeholder LTCIP Vision for Elderly & Disabled Develop “system” that:
– Provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus
– Pools associated (categorical) funding– Is consumer driven and responsive– Expands access to/options for care– Utilizes existing providers
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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 federal and state funding
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Mrs. C
84 year old woman lives alone CHF, HTN, diabetes, hearing and vision
loss, IADL dependencies 16 medications by 6 MDs Medicare and Medi-Cal beneficiary Only child lives in Chicago
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Client Referral Patterns
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9Journal of the American Geriatrics Society, Feb. 1997
In-HomeServices
DayHealthCare
AcuteHospital
TransitSkilledNursingFacility
MedicalSpecialty
MealsService
PrimaryCare
MRS.C.
Ideal System
Mrs. C & Care
Manager
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From Vision to Service Delivery Model… Explore Healthy San Diego due to:
– Access, education, prevention– Advocacy– Cost-effectiveness– Population-based– Existing infrastructure– Stakeholder-designed, BUT
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HSD Expansion Areas…
Tailor the program for chronic care of aged and disabled persons
Provide “wraparound” services Provide chronic care management on a
population basis Receive adequate reimbursement via
Medi-Cal or Medi-Medi dual cap
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Where are we now?
May ’02, BOS: “give us 3 options” Since then: Dr. Mark Meiners assists
w/strategies development:– Network of Care– Physician Strategy – HSD Health Plan/Pilot Projects
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Network of Care Beta testing with
– consumers and caregivers– community based organizations– other providers, Call Center staff
Develop “continuous quality improvement” Support 2 service delivery models Measure behavior changes of providers and
consumers Assess potential as HSD+ info and
communication database
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Physician Strategy
Partner w/physicians vested in chronic care Develop interest/incentive for support of “after
office” services (HCBC) Identify care management resources to
support physicians/office staff to link patients and communicate across systems
Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports
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Physician Strategy (cont.)
The California Endowment has provided resources for planning
Focus groups planned w/MDs, other providers, and consumers
Implementation Plan for review by 6-05 PS implementation 7-06 with HSD+ Current HeartPartners opportunity
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Health Plan Pilots
Pilots to do small, voluntary models of care integrated across the health, social, and supportive services continuum:– Private entity to contract with State through
RFP with stakeholder support (AB 2822)– Healthy San Diego Health Plans to develop
phase-in with rate cells adjusted for function and setting = HSD+
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Consultant Team for AAP
Dr. Mark Meiners, National Program Director, RWJ Medicare/Medicaid Integration Program
Mercer Government Human Services Consulting
LTCIP Staff and Stakeholders
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Administrative Action Plan for Healthy San Diego Plus (HSD+)
1. “Vision” for chronic care system
2. Governance and administration
3. Population, services, delivery system
4. Care management and integration
5. Financing and cost neutrality
6. Quality management & improvement
7. Integrated information system
8. Phase-in strategy
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AAP Highlights
Begin voluntary enrollment July ‘06 for 300 elderly per month, Medi-Cal or Medi-Medi
Use rate cells adjusted for care setting and functional level
DHS & CMS contract with extensive provider networks (health & social services)
Care manager & enrollee at “hub” Quality control mechanisms required
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Overview: Milestones and Target Dates
Draft AAP discussion w/ LTCIP PC (today) Update County BOS (5/04) Revise AAP; Gain consensus (4/04-6/04) Submit County-approved AAP to DHS OLTC
(6/30/04) Present concept paper to CMS (9/04) Waiver approved(s) (7/05) State contract awards determined (2/06) Pre-enrollment activities (3/06-5/06) Begin Phase I implementation (7/06)
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Governance and Administration
Expand HSD Infrastructure: Operating Agency and Governing Body
Pre-qualify Provider Networks through RFSQ process
3-way contract: DHS/CMS/Provider Network Medicare/Medi-Cal caps pooled at plan level System mgmt – County BOS, HHSA Director Service mgmt – contracting provider network
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HSDJoint Consumer &
Professional Advisory Committee
HSDProgram Manager
County of San Diego, HHSA Director
Policy & Program Support Division Deputy Director
Medical Care Program Administration Senior Program Manager
HSD+Program Manager
Analysts III
Analysts II
Sup Com Hlth Prom Specialists
Sup Com Hlth Prom Specialists
HSD+ Organization Chart
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Governance & Administration: Milestones and Target Dates
Expand membership of Joint Committee (1/05-1/06)
Present/discuss draft of RFSQ (6/05) Finalize and release RFSQ (9/05) Complete RFSQ evaluations and forward to
State (1/06) Perform readiness review of contractors (2/06-
4/06) Train additional HSD+ staff; make other
systems modifications (1/06-12/06)
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Population, Scope of Services, Delivery System
Begin with elderly (65+); phase in younger disabled at later date
All Medicare & Medi-Cal state plan services(State plan services for Medi-Cal only). Plus value-added home and community-based services.
Provider networks responsible for network development & coordination
MOU’s for frequently used off-plan services Consumer Interface/ Cultural Competence Demonstration of stakeholder support
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Population, Services, Delivery System: Major Milestones and Target Dates
Complete Population and Scope of Services forms (10/04)
Establish budget neutrality criteria (12/04) Establish provider network requirements (4/05) Develop policy regarding off-plan service
coordination (6/05) Finalize call center consumer interface protocols
(1/06-4/06) Define “complex care needs” (6/05) Update/expand MOU’s (1/06-6/06)
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Care Management & Integration
Care manager & enrollee at “hub” of system Provider Networks sub-contract for care
mgmt w/ AIS and/or CBO Care mgmt standards will be specified in
RFSQ “No wrong door” entry to AIS Call Center for
eligibility & options counseling Standardized assessment by contractor to
determine level of care Contractor/Consumers engaged in chronic
care self-management (Com. Ed Workgroup)
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Care Management & Integration: Milestones and Target Dates
Define minimum care mgmt & integration standards for RFSQ (1/05)
Define minimum contents of Integrated Care Plan (3/05)
Determine standards for Contractor evaluations of care manager (5/05)
Define contents and accessibility of care mgmt database (5/05)
Develop web-based data system to support chronic disease self-management (5/06)
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Financing and Cost Neutrality
Dual funding from Medi-Cal and Medicare will allow a single contractor to provide the most appropriate and cost-effective combination of services for individuals
Multiple Medi-Cal capitation cohorts (to match reimbursement to risk)
During first phases of implementation offer risk sharing and/or stop-loss mechanisms to contractors
Medicare capitation structure still to be negotiated Rates that are developed must be budget neutral to
be approved
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Financing and Cost Neutrality: Milestones and Target Dates
Contract/plan in place for actuarial support (9/04) Review detailed reimbursement approach with LTCIP
Planning Committee and potential contractors (12/04) Perform cost analysis for budget neutrality (1/05) Perform gap analysis of system(s) requirements
related to reimbursement approach (2/05) Obtain State approval of reimbursement approach
(3/05) Begin capitation rate development process (4/05) Final capitation rates developed (12/05)
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Quality Management & Improvement
Contractors will be required to demonstrate utilization review and management processes
Contractors will have primary responsibility for resolving complaints and appeals (grievances), however other levels of review will exist
RFSQ will specify reporting related to quality – focus on outcomes and performance improvement
RFSQ will specify quality improvement initiatives External surveys and reporting will be performed
such as EQRO, HEDIS, and CAHPS
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Quality Management & Improvement: Milestones and Target Dates
Define the complaint and appeals protocol (1/05) Define County’s method/process to monitor quality
management requirements (2/05) Develop policies and standards of utilization review
and management for RFSQ (3/05) Define required QM reporting for RFSQ (4/05) Determine Contractor standards for provider
credentialing and provider profiling Draft materials to be provided in writing to consumers
about the complaint and appeals process (1/06)
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Integrated Information System Web-based system that supports the integration of
care across the continuum of providers of health, social, and supportive services
Contractors will be required to collect and retrieve data on an individual patient basis and in the aggregate
Pre-implementation planning will examine the Network of Care component as a potential vehicle to be the over-arching information and communication system
Two data support programs will be expanded for the aged and disabled population – Panorama View and GeoAccess
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Integrated Information System: Milestones and Target Dates
Perform a gap analysis of system requirements against current system capabilities (2/05)
Plan with stakeholder to expand Panorama View and GeoAccess capabilities (3/05-5/05)
Define contents and accessibility of case management database (5/05)
Systems modifications and/or development (1/06-12/06)
Develop web-based data system to support chronic disease self-management (5/06)
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Phase-in Strategy
Begin with voluntary enrollment of age 65+ to allow time for contractors to build expertise, an adequate network of providers, and infrastructure
Determine evaluation criteria with baseline data and benchmarks to measure the success of phases and to be able to justify moving to the next phase
Goals and performance criteria for each phase will be established and continuously modified with implementation
Implementation of program will be completed in no more than four phases (maybe fewer)
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Phase-in Strategy: Milestones and Target Dates
Define evaluation plan criteria for baseline data and benchmarks for Phase I (1/06-5/06)
Enrollment of members with contractors (5/06-6/06) Phase I implementation begins for 65+ in greater
metro San Diego (7/06) Phase II implementation begins, 65+ in entire County
(7/08) Phase III implementation begins, ages 21+ in entire
County (7/10) Phase IV, mandatory enrollment begins (7/12)
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Questions & Comments