Accountable Care Collaborative: Medicare-Medicaid Program (ACC:MMP) - PowerPoint PPT Presentation

Accountable Care Collaborative: Medicare-Medicaid Program (ACC:MMP) Making Medicare and Medicaid work better together for our clients 1 Colorado Department of Health Care Policy and Financing

Department’s Mission: Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources 2 Colorado Department of Health Care Policy and Financing

What we will cover today 1. Introduction to ACC: Medicare-Medicaid Program 2. Service Coordination Plan (SCP) Introduction 3. Coordinating with Other Providers 3 Colorado Department of Health Care Policy and Financing

What we will cover today 1. Introduction to ACC: Medicare-Medicaid Program 2. Service Coordination Plan (SCP) Introduction 3. Coordinating with Other Providers 4 Colorado Department of Health Care Policy and Financing

Program Background • 10 million people nationwide rely on Medicare and Medicaid • Fragmented fee-for-service (FFS) delivery system • Affordable Care Act authorization of state-led demonstration programs to integrate care • Colorado is one of 15 participating states • 32,000 eligible clients 5 Colorado Department of Health Care Policy and Financing

Colorado’s Medicare -Medicaid Enrollees Top Five Mental Health Diagnoses for MMEs Depressive Disorder NEC Anxiety State NOS Tobacco Use Disorder Other Alteration of Consciousness Schizoaffective-Unspec Percent of MMEs 38% with Mental Health Diagnosis 6 Colorado Department of Health Care Policy and Financing

ACC: Medicare-Medicaid Program Goals • Improve MME health outcomes • Decrease unnecessary and duplicative services • Promote person-centered planning • Improve client experience through enhanced coordination and quality of care 7 Colorado Department of Health Care Policy and Financing

8 Colorado Department of Health Care Policy and Financing

ACC Components Statewide Data and Analytics Contractor (SDAC) Regional Care Primary Care Collaborative Medical Providers Organizations (PCMPs) (RCCOs) 9 Colorado Department of Health Care Policy and Financing

Delegated Care Coordination • ACC allows RCCOs to delegate care coordination to PCMPs and other appropriate entities • Through delegation, PCMP completes SCP  RCCO still responsible for ensuring SCP completion and timely updates when delegated to PCMP • Provider responsible for coordinating care with client’s other providers and care coordinators 10 Colorado Department of Health Care Policy and Financing

ACC: Medicare-Medicaid Program Vision Traditional, Regional, outcome- MMEs MMEs unmanaged focused, client/family- Now Later Fee-for- centered coordinated Service model system of care 11 Colorado Department of Health Care Policy and Financing

Current System for MME’s Often does not coordinate Primary Care, Acute, Sub-Acute, or Specialty Care Community Acute care -Based and Services hospital and services Supports Clients with LTSS receive: Case management - Single Entry Point (SEP) or Community Centered Boards (CCB)  For clients not receiving Long-term Supports and Services (LTSS): Often no one available to coordinate any of their services 12 Colorado Department of Health Care Policy and Financing

New System for MME’s Coordination of Primary Care, Acute, Sub-Acute, and Specialty Care RCCO Coordinates both acute and community- based services for ALL enrolled clients Service Coordination clients receiving LTSS: Existing Long-Term Care Plan (LTC) “Service Plans” and other assessments Community largely inform the SCP Acute Care -Based and Services Hospital and services Supports 13 Colorado Department of Health Care Policy and Financing

Program Enrollment • 32,000 people to be enrolled over seven months  Starting Sept. 1 and ending March 2015 • Clients separated into four categories to for phased in enrollment:  Community Well,  Waiver High,  Waiver Low, and  Nursing Facility 14 Colorado Department of Health Care Policy and Financing

Program Enrollment: Categories Defined Client Enrollment Classifications Community These clients are not nursing home certifiable and do not live in a nursing facility nor Well use waiver services on a consistent basis . These clients are not living in a nursing facility and utilizing waiver services on a Waiver Low consistent basis . These clients are also not living in a nursing facility , but are very high utilizers of waiver Waiver High services . These clients had to have an average PMPM of greater than $4,800 in waiver services to be considered as part of this delivery system. These clients reside in a nursing facility and have a nursing facility level of care . A client Nursing must have at least three consecutive months of nursing facility service to be considered Facility as part of this population. (Clients with less than the three months of nursing facility service are considered “short term” and are captured in one of the other delivery Population systems.) 15 Colorado Department of Health Care Policy and Financing

Monthly client Enrollment by Classification 7500 clients/month maximum Sept Oct Nov Dec Jan Feb Mar MMEs currently in ACC Community Community Well Well PCP in ACC PCP in ACC Community Community Well No Enrollment Well PCP not ACC PCP not ACC Waiver Low Waiver Low PCP not ACC PCP not ACC Waiver High PCP not ACC Remainder of Nursing Nursing Facility Facility residents for residents for which CO which CO Medicaid is Medicaid is primary payer primary payer (stay >90 (stay >90 16 days) days) Colorado Department of Health Care Policy and Financing

What we will cover today 1. Introduction to the ACC: Medicare-Medicaid Program 2. Service Coordination Plan Introduction 3. Coordinating with Other Providers 17 Colorado Department of Health Care Policy and Financing

Care Coordination Requirements Centers for Medicare and Medicaid Services (CMS) requires:  “Plan of care” for each enrollee • Colorado’s plan of care is Service Coordination Plan (SCP)  Enrollees determined “high risk” to have SCP completed within 90 days • All other enrollees 120 days  SCPs must be updated every six months or as needed to ensure client is on track and achieving health care goals  Process for Provider Communication and Collaboration to complete SCP = Provider Protocols 18 Colorado Department of Health Care Policy and Financing

What is the Service Coordination Plan? • Cornerstone of Program • Helps identify gaps in care and duplicative services • Documents clients ’ short- and long-term goals • Blueprint for meeting client goals and improving health outcomes 19 Colorado Department of Health Care Policy and Financing

Service Coordination Plan • Promotes proactive, person- centered, strength-based coordination of services and supports , including:  Coordinating physical, behavioral and social health needs for clients w/complex conditions  System-level oversight and support for people w/multiple case managers  Promoting patient activation 20 Colorado Department of Health Care Policy and Financing

Service Coordination Plan • Single, comprehensive view of all elements needed to coordinate client’s physical, behavioral and social health care services and supports • Promotes communication and coordination across delivery systems and among providers • Completed w/client, capturing their needs and wants 21 Colorado Department of Health Care Policy and Financing

Service Coordination Plan Development • SCP created through collaborative effort between HCPF and RCCOs • Incorporated feedback from workgroup, RCCO care coordinators and advocates • Tested by RCCO care coordinators during development process 22 Colorado Department of Health Care Policy and Financing

High Quality Service Coordination Plan • Shows you client’s wants, needs and gaps in service • Provide documentation that resources were provided to client and their needs were met 23 Colorado Department of Health Care Policy and Financing

24 Colorado Department of Health Care Policy and Financing

RCCO Determined High-Risk Eleven domains of prioritization: • Duration of 1915(c) HCBS waiver • Presence and severity of enrollment chronic conditions • Functional, behavioral and/or • Residential housing status cognitive risks • Poly-Pharmacy • Change in existing Care Manager • Gaps in care relationship • Stability of support system • Observed risks for being institutionalized • Change in caregiver status/support • Inpatient or emergency department utilization 25 Colorado Department of Health Care Policy and Financing

Completion and Review Timeline All other clients 90 days 180 days (3 months) (6 months) 120 days (4 months) High-risk clients SCP review for all clients 26 Colorado Department of Health Care Policy and Financing

SCP – An Ongoing Process • RCCO/Care Coordinator Review and revise conducts initial assessment every 6 months or • Works w/client and PCMP to maintain going forward as needed Examples of as-needed situations: • Significant change in the client’s needs • Acute or critical incident • Client, family or provider request • Care transition • Abuse or neglect 27 Colorado Department of Health Care Policy and Financing