MARYLAND DUAL ELIGIBLES CARE DELIVERY INITIATIVE STAKEHOLDER - PowerPoint PPT Presentation

MARYLAND DUAL ELIGIBLES CARE DELIVERY INITIATIVE STAKEHOLDER WORKGROUP - NOVEMBER 15, 2016

AGENDA ¡ Care Management Roles and Responsibilities for D-ACO and PCHH ¡ Beneficiary Counseling ¡ Quality Measurement ¡ Risk Adjustment Methodology ¡ Next Steps – Stakeholder Engagement Process 2

THEORY OF CHANGE CHARACTERIZED IN DRIVER DIAGRAM Achieve and Sustain Goal High-Value Coordinated Care for Dual Eligibles Primary Drivers Health Home Care Coordination Ease of Use Accountability Continuous beneficiary Seamless care handoffs Unified processes and Incentives for quality and care relationship with a between providers, across reliance upon existing cost effectiveness across principal provider settings community resources Medicaid & Medicare • Beneficiary chooses and • Beneficiary’s medical, • Beneficiary’s medical, • Care coordination is remains formally linked to a behavioral, LTSS and social behavioral, LTSS and social recognized as a function Person-Centered Health service elements all service elements all needing to be paid for Secondary Drivers Home (PCHH) suited to considered in plan considered in plan • Providers rewarded for personal circumstances • Health data exchange • Health data exchange achieving quality and cost • PCHH is responsible for enables real-time awareness enables real-time awareness savings goals; moderate assessing needs, care and readiness as and readiness as downside risk in ACOs planning and leading beneficiaries transit across beneficiaries transit across • Medicaid and Medicare coordination of all care settings of care settings of care dollars combined to gain beneficiary needs • All setting-specific care • All setting-specific care accountability for whole- • PCHH supported by ACO coordinators sync up with coordinators sync up with person spending care management PCHH to eliminate PCHH to eliminate • Align with all-payer model duplication or conflict duplication or conflict 3

D-ACO WILL RUN IN MOST POPULOUS AREAS CECIL Full Duals by ALLEGANY WASHINGTON CARROLL HARFORD 1,237 GARRETT 1,960 2,648 1,570 2,352 County 719 FREDERICK BALTIMORE 2,154 10,666 <1,500 beneficiaries BC KENT 356 HOWARD 3,046 1,501-3,000 18,411 MONTGOMERY ANNE QUEEN 14,235 3,001-7,500 ARUNDEL ANNE’S 4,160 407 CAROLINE 7,501-10,000 691 D-ACO model will run initially in ¡ PRINCE TALBOT GEORGE’S 521 8,711 10,001+ Baltimore City, Baltimore County, Montgomery County, and Prince George’s County – home to almost CHARLES DORCHESTER 1,573 873 two-thirds of the population WICOMICO ST. MARY’S 1,698 1,127 WORCESTER Additional cross-county border areas ¡ 670 SOMERSET 562 may be included to preserve provider- beneficiary relationships Potential expansion to wider area once ¡ concept proven viable 4

D-ACO AND PCHH ROLES To achieve care redesign Beneficiary and transformation, the Identification role of care management D-ACO and care coordination is Evidence- Comprehensive a responsibility of the Based Care Networks Care D-ACO but shared and Coordination delivered by the PCHH to the extent reasonable. Person-Centered, Holistic Community Driven Assessment Centralized PCHH Population- Beneficiary Based Care Record Longitudinal Transition Care Plan Support Lead Interdisciplinary Care Team HIT and HIE Sophisticated Infrastructure Analytics Cross-Training and Resources 5

BENEFICIARY-TARGETED MATERIALS ¡ DHMH will use the approved D-ACO-specific beneficiary materials for the counseling and designation process ¡ D-ACOs will use approved materials for ongoing communication and education of designated beneficiaries ¡ Materials will allow D-ACOs to describe location, hours, services, network, and other common attributes of the D-ACO program and will afford an opportunity for each D-ACO to highlight its unique approach ¡ Materials will be translated into prevalent languages and will be culturally and disability competent 6

BENEFICIARY COUNSELING ¡ DHMH or a designee will provide counseling on the benefits of the D-ACO program as well as the information about the PCHH to which the beneficiary would be designated absent an affirmative choice At least 60 days prior to the effective date of designation, DHMH or a designee will ¡ conduct multiple communication efforts including mail and/or telephone ¡ The counseling process will start with the beneficiary’s selection of the PCHH; if the PCHH exclusively participates in a D-ACO, the PCHH election will serve as the D-ACO election, if non-exclusive, counseling till then continue to discussion of D-ACO election options ¡ Counseling will provide the PCHH and D-ACO options to the beneficiary based on his or her historical Medicare and Medicaid claims data, diagnostic history, and geographic location ¡ Individuals in the northern region (Baltimore City and Baltimore County) will be precluded from electing a D-ACO that operates only in the southern region (Prince George’s County and Montgomery County) and vice versa 7

QUALITY MEASUREMENT OVERVIEW ¡ Goals ¡ Measure selection ¡ Initial reliance on MIPS-NQF measures ¡ Core Quality measures – Current NQF recommended ¡ ICD-10 ¡ Transformation over time ¡ Measures Under Development (MUD) ¡ HCBS and Examples ¡ Approach to aggregating measure-level performance to calculate a D- ACO quality score 8

QUALITY MEASUREMENT ¡ Goals for quality measurement system Protect beneficiaries ¡ Ensure cost savings are associated with improved quality ¡ Create alignment of measurement across programs ¡ Case mix adjustment where applicable ¡ ¡ Quality measure selection strategy Ensure coverage of key domains of care for dual eligible beneficiaries, including social ¡ factors and quality of life Rely upon validated measures from credible stewards ¡ Align measures and reporting requirements with other programs and minimize number ¡ to reduce reporting burden Focus process measures on care coordination ¡ 9

QUALITY OF CARE FOR DUALS National Quality Forum (NQF) – Repository for systematically developed and evolving § Quality Measures – uses expert panels for Measures Under Consideration (MUC) and Measures Under Development (MUD) “Advancing Person-Centered Care for Dual Eligible Beneficiaries through Performance § Measurement” – 35 measures and, also recommended starter set of core measures August 2015 Cross cutting measures and generally not disease-specific § Minimize data collection burden § Alignment with other federal and state programs § “Measure Status Report” tracks each NQF approved measure: identifies Measure Steward, § numerator and denominator, risk adjustment, data source, and more. The Quality Horizon – the future § electronic Clinical Quality Measures – eCQMs derived from electronic Health Records § New Community Integration/LTSS focused measures are under development § 10

DUALS CORE QUALITY MEASURES (1 OF 2) NQF #/ Measure Measure Data Source Steward Ini$a$on and Engagement of Alcohol and Other Drug Dependence Treatment Claims/ E H R 4/NCQA CAHPS Health Plan v 4.0 - Adult ques$onnaire Beneficiary Reports 6/AHRQ Controlling High Blood Pressure Under Reconsidera$on NQF 18/NCQA Preven$ve Care and Screening: Tobacco Use: Screening & Cessa$on Interven$on Claims/E H R /Paper or Registry 28/AMA Consor$um Medica$on Reconcilia$on - Post Discharge Claims/E H R /Paper or Registry 97/NCQA Falls: Screening, risk-Assessment, and Plan of Care to Prevent Future Falls Claims/E H R /Paper 101/NCQA, AMA Consor$um 3-Item Care Transi$on Measure at Hospital Discharge (Needs, responsibility and Beneficiary Reported Data 228/University of Colorado medica$ons) Advanced Care Plan Claims/E H R 326/NCQA, AMA Consor$um Preven$ve Care and Screening: Screening for Clinical Depression and Follow-Up 418/CMS, Mathema$ca, Claims/Paper/Other Plan Quality Ins$tute of PA 419/CMS, Mathema$ca, Documenta$on of Current Medica$ons in Medical Record Claims/Other/Registry Quality Ins$tute of PA 421/CMS, Mathema$ca, Adult Weight Screening and Follow-up Claims/Other/Paper/ Registry Quality Ins$tute of PA Follow-Up A^er Hospitaliza$on for Mental Illness Claims/E H R 576/NCQA 11