IEHP Narcotics Claims Costs Narcotics - All LOBs Total Paid $2,000,000.00 $1,800,000.00 $1,600,000.00 $1,400,000.00 $1,200,000.00 $1,000,000.00 2014 2015 $800,000.00 $600,000.00 $400,000.00 $200,000.00 $0.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
• Heroin 0.3M • Meth 0.4M • Crack 0.4M • Hallucinogens 1.0M • Cocaine 1.7M • Tranquilizers 2.0M • Pain Relievers • Tobacco 69.5M 5.0M • Marijuana 19.0M • Alcohol 136M
Poorly Treated Chronic Pain More than 116 million American adults suffer from pain, more than those affected by heart disease, cancer and diabetes combined (Relieving Pain in America, Washington,DC: National Academies;2011) Total related annual costs: $635 billion (Relieving Pain in America, Washington,DC: National Academies;2011) Poorly treated pain affecting approximately 75 million Americans (American Pain Foundation. Annual report. 2006) Poorly treated chronic pain negatively affects physical, psychological and social well being frequently leading to sleep disturbance, depression and anxiety (Argoff CE. The coexistence of neuropathic pain, sleep and psychiatric disorders: a novel treatment approach. Colin J Pain. 2007;23(1):15-22)
Prescription Drug Abuse: Fastest Growing Substance Use Disorder (SUD) Opioids have been used for thousands of years for analgesic properties (Deer ed. American Academy of Pain Medicine, Textbook 2013) 90% of patients being treated in pain management settings are receiving opioid therapy (Paulozzi et al. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27) In patients being treated for a chronic pain condition: 15% are concomitantly abusing prescription drugs and 35% are using illicit drugs (Manchikanti L. Prescription drug abuse: what is being done to address this new drug epidemic? Pain Physician 2006;9(4): 287-321)
Prescription Drug Abuse More than 6 million Americans are abusing prescription drugs, more than the number abusing cocaine, heroin, hallucinogens and inhalants combined. About 75% are in the opioid analgesic class (Deer ed. American Academy of Pain Medicine, Textbook 2013) The number of overdoses due to prescription opioids now surpasses both cocaine and heroin overdoses combined (Paulozzi et al. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27) Cost related to prescription drug abuse: nearly $200 billion from medical costs, crimes involved and loss of productivity (Paulozzi et al. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27)
Multidisciplinary Treatment Psychiatry Psychology SUD Treatment Alternative/ Medical Treatment Complementary Physical Therapy Treatments
Integrated Pain/Behavioral Health Treatment Pilot: Multidisciplinary Team • Medical/Pain Specialists • Medication management and opioid taper • Interventional treatments, i.e. injections • Psychologists and SUD specialists • Physical reconditioning Osteopathic manipulative treatment (OMT) • Physical (PT) and Occupational (OT) Therapies • Passive modalities (e.g., ultrasound, electrical, stimulation, massage) • Neurophysiology education • Alternative/Complimentary • Chiropractic care • Naturopathic/Homeopathic treatments, hydrotherapy • Diet coaching • Mindfulness/Meditation
Integration In California: Agenda for 2015/16 The Impact of the ACA on California From silos to accountable organizations New benefits require changes in responsibility Expect movement from “carve - out” to “carve - in” funding Health Home Array to add Behavioral Health Homes Promoting innovation county by county Piloting new BH integration models in primary care New behavioral health home models for SMI population served by county mental health and innovative wrap around programs (e.g. telecare)
Achieving the Triple Aim by integrating the social and behavioral determinants of health into health care payment and delivery systems
Cal-MediConnect Provider Summit Best Practices For Care Coordination Deborah Miller Vice President, Healthcare Services Molina Healthcare of California June 23, 2015
Molina Care Coordination • Helping members/families access medical benefits and services (LTSS, LTC) • At the right time, place and cost • Based on assessed needs : behavioral health, medical, psychosocial, functional status • Based on member’s preferences and willingness to participate • In concert with PCPs, specialists, LTSS providers and other interdisciplinary participants and providers 36
Care Coordination-Other Provider Types • Hospitals • Home health, hospice, palliative care • SNF and LTC, board and care facilities • Urgent care providers • Behavioral health providers, county agencies • IHSS, MSSP, CBAS • Dialysis center staff • Independent living centers 37
Care Coordination Most effective with provider involvement Common reasons to contact physician: • Invite to the interdisciplinary care team meeting • Obtain PCP involvement in care coordination • Share medication concerns, pharmacist input • Giving/getting information - change in health status • Share assessment information - care plan development, psychosocial issues, LTSS, plan care coordination • Work with physician extender when physician unable to participate directly in ICT 38
IPAs and Medical Groups • Those with MSO or care management departments - very receptive to participating in care coordination • Will often send their case manager to the ICT • Will often invite plan’s CM to their ICT • Receptive to contributing to care plan, sharing member address/phone number, other relevant information • Appreciate our field work with member, care transitions, follow up with member, LTSS service coordination • JOMs - focus on what can be improved • Plans want more access to group/IPA EMR 39
Interdisciplinary Care Team PCP/Specialist involvement: • Becoming more common • Now more receptive to ICT recommendations • IPA medical assistant is often the path to access the physician • PCP more likely to accept brief phone call for consult than attend a formal ICT • Physician ICT involvement is brief, can be formal or informal • R espect PCP’s time 40
Frank’s Story 41
Frank’s Interdisciplinary Team • Frank (member centric) • RN care manager - Molina • Community Connector - Molina • PCP - medical group, IPA, direct • Physician specialists • Medical director(s) - Molina • Director of LTSS-Molina • Dentist • Frank’s wife • ILS - independent living center representative • Ramp builder • IHSS liaison 42
What did Frank need/want? • Access to care - Physician that can manage complex care • Independent transfers - in and out of bed • Fewer UTIs • Healed skin wounds, no more pressure sores • Transportation to medical appointments • To go back to school • Safe access to his apartment-ramp 43
What did Frank need/want? • To link family with services (dental, medical) • To take a shower safely, regularly • Dentures • To give up • To die • A transplant • To live 44
What did Frank Get? (so far) • A caring involved PCP, access to specialists • A bed, trapeze - Independence • Dental care - access • Incontinence supplies - fewer UTIs • Functional wheelchair - Independence • On waiting list for better housing • Assessment for transplant - access to care 45
What Else Did Frank Get? • Interdisciplinary team expertise • Advocacy- psychological support • New perspective - motivation • The will to live • Hope for a better future • Better Quality of Life through interdisciplinary care coordination 46
47
48
Demara Nuzum, RN Vice President of Medical Management
NAMM CA Overview MA & Duals 67,000 Commercial 160,000 Exchange 12,000 Insurance License Limited Knox-Keene Network Statistics 15 IPAs, 575 PCPs IPA Relationships 1 Managed, 14 Owned Aetna, Blue Shield, United, Cigna, Humana, Key Relationships Anthem, SCAN, Health Net, Care 1 st , IEHP, Sharp Breadth and Depth of Network • Largest non-Kaiser provider of managed care services in S.B. and Riverside counties ~22% • Exclusive PCPs represent over 87% of enrollment • 3-5 year exclusivity terms with 11 year average tenure Strong Payer Relationships • Global risk with 8/9 senior and 3/7 commercial plans • Private label PPO/HMO commercial ACO product • Covered California HMO provider Cities/Towns with NAMM Physician Presence NAMM Primary Admitting Hospitals • Other Commercial ACO products pending Represents Area with Negligible Population Density
North American Medical Management, California, Inc. PrimeCare Medical Network, Inc Other NAMM Managed/Owned Entities Knox-Keene MSO Services Owned IPAs: IPAs: PrimeCare Medical Group of Chino Valley, Inc Coachella Valley Physicians of PrimeCare, Inc. (50%) PrimeCare of Citrus Valley, Inc. (80%) Primary Care Assoc. Medical Group, Inc PrimeCare of Corona, Inc. Mercy Physicians Medical Group, Inc PrimeCare of Hemet Valley, Inc. (Managed) PrimeCare of Inland Valley, Inc. Owned Groups: PrimeCare of Moreno Valley, Inc. Redlands Family Practice Medical Group, Inc. PrimeCare of Redlands, Inc. Physician Partners Medical Group PrimeCare of Riverside, Inc. PrimeCare of San Bernardino, Inc. PrimeCare of Sun City, Inc. Scripps IDN Management, LLC (JV) PrimeCare of Temecula, Inc. MDOps, Inc. Valley Physicians Network, Inc. (80%) Premier Choice ACO, Inc. Your Health Options Insurance Services, Inc.
Dr. Tarek Mahdi President Riverside Family Physicians 52
Questions and Discussion 53
Engaging Consumers in Care Cal MediConnect Providers Summit June 23, 2015 Moderator: Hilary Haycock, President, Harbage www.chcs.org
Jeanna Kendrick Senior Director of Care Management Inland Empire Health Plan Gilbert Sauceda Program Manager Riverside County, HICAP Kristine Loomis In-Home Supportive Services (IHSS) Client and Advocate 55
Questions and Discussion 56
Lunch: Cal MediConnect Plan Office Hours www.chcs.org
Integrating Home and Community-Based Services Cal MediConnect Providers Summit June 23, 2015 Moderator: Rebecca von Lowenfeldt, Director of LTSS Practice, Harbage Consulting www.chcs.org
Ben Jauregui Manager of LTSS Inland Empire Health Plan 59
Long-Term Services and Supports LTSS Promoting Home and Community-Based Options
CCI Workgroups Objective: Design policies, procedures, and infrastructure required to coordinate LTC and HCBS for our members. • MSSP Super Workgroup • LTC Program Design • IHSS Super Workgroup • Coordinating and Integrating • Duals/CCI Data Sharing Member Care • Gaps/Optional Services • In-House LTSS Program • External Relationships Design
New Requirements Long-Term Services and Supports Long-Term Care Home and Community-Based Services • In-Home Supportive Services • Multi-Purpose Senior Services Program • Community-Based Adult Services
Membership Utilizing LTSS
Units Established • Long-Term Care Unit established in 2013 in Utilization Management Department – 19 nurses and coordinators • LTSS Unit established in 2014 in Care Management Department – 3 nurses, 1 social worker, 2 coordinators
LTSS Unit LTSS Manager IHSS/MSSP IHSS/MSSP CBAS IHSS/MSSP Nurse CBAS Nurse CBAS Nurse Social Coordinator Coordinator Care Worker Manager Community-Based Adult Services In-Home Supportive Services and Multi-purpose Senior Services Program
LTSS Unit Activities • Identifies potential members for LTSS through referrals from care managers, encounter inpatient admissions, outpatient referrals, and provider referrals • Assist members in accessing LTSS benefits • Coordinate care between IEHP/LTSS provider/ county/community-based organizations • Identify members needing a higher level of care or formal interdisciplinary care team meeting
Support Services County Community Mental Health Resources LTSS Behavioral Disability Health Program Home Transportation Delivered Resources Meals Transition Health of Care Education Caregiver Home Health Resources Modifications Navigators
Support Services • LTSS social worker – links members to critical resources to prevent or delay SNF • Disability Program – links members to community resources – Identify and build relationships with CBOs that serve seniors and people with disabilities – Link members to CBOs – On-line community resource guide via 2-1-1
Challenges • Educating staff about social needs and services • Establishing relationships with providers • Critical to listen in order to understand their regulations, abilities, limitations and concerns • Balance between service demand, having resources in place and revenue flows • Staffing is difficult because of fluid timelines
Success Stories • 64 year old male living alone. Physical and cognitive disabilities. Denied IHSS twice. Care manager referred member to IHSS unit and care manager assisted with application. Member approved for IHSS. • 56 year old female receiving 60 hours a month. After surgical procedure needed temporary raise in IHSS hours. LTSS unit coordinated with the county to temporarily increase hours to 209. • 50 year old male, referred by county MH to CBAS center. Before CBAS, was homeless, several psych inpatient stays, several B&C and R&B. Several ER visits. Attends CBAS 4 days a week regularly and living at same B&C for last 6 months - no ER visits.
Questions or Comments? LTSS Promoting Home and Community-Based Options
Cal-MediConnect Providers Summit Coordinating Care in Institutional-based Long-Term Services and Supports John A. Roohan, M.D. Medical Director, Long Term Care Molina Healthcare of California June 23, 2015
Overview of MHC MMP Long Term Care (LTC) Members in IE • Molina currently has approximately 800 LTC members participating in the CCI program who reside in LTC facilities in the Inland Empire • 95 contracted LTC facilities in both IE counties 73
Aligning with DHCS Stated Goals of the CCI Promote Improve Access Promote Person- Independence in to Care Centered Planning Community Right Care Cost Savings for State and Federal Right Time Government Right Place 4
Aligning with DHCS Stated Goals of the CCI Promote Improve Access Promote Person- Independence in to Care Centered Planning Community Right Care Cost Savings for State and Federal Right Time Government Right Place 4
Improving Access to primary care in LTC setting • Molina is committed to ensure that our members residing in LTC have access to primary care physician services. • For our LTC members who have not opted out from the Medicare portion of CCI: Molina contracts with community based physicians who are willing and able to fulfill the role of primary care physician. 76
Molina has developed a document to outline our expectations and requirements for primary care physicians whose assigned members reside in nursing facilities: Physician Responsibilities in a Nursing Facility • Comprehensive Medical Case Management: participation to ensure coordination of specialty, ancillary services • Health Promotion and Disease Prevention; Preventative Health Services: age, gender, and condition specific screenings, health education and promotion • Standards for timely access to care: state-approved contractual standards • Participation in Quality Improvement and Performance programs: HEDIS, Annual Comprehensive Evaluations (ACE), submission of accurate and timely data for risk adjustment • Provide medically necessary visits at regular intervals , as appropriate for the member’s medical needs and level of care required • Participation in all coordination efforts: ICT meetings (scheduled and ad hoc), transitions of care program, identification of potential members who would be able to transition back into the community • Grievance program and Reporting: timely, accurate responses 77
Aligning with DHCS Stated Goals of the CCI Promote Improve Access Promote Person- Independence in to Care Centered Planning Community Right Care Cost Savings for State and Federal Right Time Government Right Place 4
Interdisciplinary Care Team (ICT) Meetings 79
ICT Composition The ICT consists of the member, the member’s family and/or caregiver, and internal and external stakeholders. Example stakeholders include, but are not limited to: Internal External Member Stakeholders Stakeholders • Physicians • Case Managers • Facilities • Medical Director • Home Health Care • CAM Staff • Long-Term Care • Community Connectors • Long-Term Services and • Social Worker/ Behavioral Supports Health Specialist • Pharmacist 80
Cases to be presented in an ICT meeting are identified through: • Historical data and predictive software to identify highest risk members • Health Risk Assessments (HRAs) • Recent transition(s) of care • Member or surrogate decision maker request • Facility or provider request 81
What are some of the goals of ICTs? • Develop care plans which focus on individual needs for members and their families • Improve care by increasing coordination of services, including long term services and supports (LTSS) • Encourage innovation around difficult problems • Serve members of diverse cultural backgrounds • Use time and resources more efficiently • Facilitate shift in emphasis from acute, episodic care to long-term and preventative care • Promote high quality, comprehensive, and cost-effective member care 82
Shared Process All ICT members, including the member or family, will complete the following activities together: • Identify the member’s main health concern • Clarify the primary guidance or information being sought from the ICT • Discuss member’s: • Relevant medical conditions • Behavioral health conditions • Medications • Functional status • Family or resource status • Environment • Existing care plan and interventions already implemented 83
Shared Process (continued) • Define and expand any problems • Develop and evaluate potential solutions or management plans. Each team member contributes his/her own unique perspective. • Decide on goals • Summarize the plan and agree on distribution of tasks across team members 84
ICT Follow-up • Care manager is responsible to: • Distribute the updated care plan summary to internal and external stakeholders • Ensure proper implementation of the care plan and to identify concerns or barriers • Follow-up on a regular basis with the member, family, and facility 85
Aligning with DHCS Stated Goals of the CCI Promote Improve Access Promote Person- Independence in to Care Centered Planning Community Right Care Cost Savings for State and Federal Right Time Government Right Place 4
A success story: transitioning back to the community level of care from LTC setting • Mary is a 65 year old female resident of the Inland Empire who was hospitalized for osteomyelitis (bone infection). • She received treatment in an acute hospital and was transferred to a SNF for skilled care and IV antibiotics. The member then transitioned from skilled to custodial level of care due to her inability to return home related to her medical and physical needs. • She had a history of diabetes, Parkinson’s disease, and depression. • Member subsequently was enrolled as a MMP member with Molina. • During her stay at the SNF, the member expressed her desire to return to the community. However she no longer had access to affordable housing; so it was especially challenging for the team at the facility to assist her. 87
Transition story (continued): • Through the ICT process, a referral was made to the California Community Transitions (CCT) organization to assist Mary to return to the community. • The Molina case manager was able to work collaboratively with the member along with CCT and the SNF in order to ensure the member had the services they needed. • The Molina Long Term Services and Supports (LTSS) Liaison also worked with the County IHSS program to ensure that the member was assessed for IHSS while at the SNF. – IHSS was able to complete an expedited initial assessment and then follow up and assess her again upon discharge. – Expedited assessments through IHSS are a new benefit through CCI. • The CCT program was able to assist with housing, utilities, stove, refrigerator, DME and even groceries. 88
Transition story (continued): • As a result of this collaborative effort, Mary was able to transition into her own apartment on May 1, 2015. • The Molina case manager, Molina LTSS liaison, the CCT organization, SNF staff, DME vendor, IHSS, and the member’s family all worked together to make sure that the members needs were met. • The Molina case manager continues to follow up with Mary and her family at least weekly. He has been assisting to coordinate her follow up appointments, requests for additional DME, and specialists. • She has expressed how happy she is to be living independently once again with the help of everyone involved. 89
Multiple challenges to transitioning from LTC back to the community • Mental health and substance abuse issues • Chronic homelessness • Short term homelessness: access to affordable housing in general, affordable housing lost after members are in LTC (e.g. lose senior apartment during acute and rehabilitative care) • Lack of functioning family or social support network • High complexity medical needs: – Polypharmacy – Homebound care – Wound care 90
Looking ahead… 1. Further strengthen our partnership with key providers like yourselves by ensuring we have provided you with the resources & support you need to effectively care for our members 2. Identify creative/collaborative strategies to overcome barriers to delivery of cost effective, quality care 3. By doing so, encourage retention of members in the CMC program, as well as re-enrollment 91
Darren Gray Social Worker Loma Linda University Medical Center CBAS Adult Day Health Services 92
Questions and Discussion 93
Leveraging Community Resources Cal MediConnect Providers Summit June 23, 2015 Moderator: Alexandra Kruse, Senior Program Officer, CHCS www.chcs.org
Disability Program
Mission B A R R I UNEVEN E PLAYING R FIELD HEALTHCARE SERVICES COMMUNICATION ACCESS
1989 THE FIRST BEST BUDDIES CHAPTER WAS CREATED ACCESS
Provider office Accessibility information readily available for Members
Recommend
More recommend
