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Developing Service Packages for Integrated Care February 20, 2014 11:30 am – 12:30 pm EST Developing Service Packages. Lynn Kellogg, CEO Region IV Area Agency on Aging, MI. Offering Choices for Independent Lives. Aging Network’s Evolution to Medical Partnerships

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Developing Service Packages for Integrated Care

February 20, 2014

11:30 am – 12:30 pm EST


Developing Service Packages

Lynn Kellogg, CEO

Region IV Area Agency on Aging, MI

Offering Choices for Independent Lives


Aging Network’s Evolution to Medical Partnerships

Simultaneous development on 2 levels…

Level 1: Product development with Health Plans/Funders

Integrated Care [IC] – product design associated with Michigan’s Integrated Care demonstration for persons with dual eligibility [Medicare & Medicaid]

Level 2: Product development w/ local hospitals, FQHCs, PCP groups

Interagency Care Teams [ICT]: product design associated with avoiding hospitalization readmissions, ACOs, PCMHs and other best practices.


Service Packages…

Integrated Care [IC] –Level 1

Process: “Unbundling” Medicaid waiver, OAA and state initiatives and repackaging to conform to the Patient Benefit Plan [PBP] required of all health plans competing for a role in the proposed IC demonstration. Includes re-pricing, re-bundling, determination of ability to assume risk and scalability

Service examples: supports coordination, transition, assessment, vendor management, housing assistance, self-directed care, all HCBS, evidence-based training

Interagency Care Team [ICT] - Level 2

Process: Working w/ case management staff and PCPs from different entities serving the same individuals to achieve better outcomes

Service: Creation of ICT to link medical & HCBS providers; capability to shift lead across agencies; HIPAA communication tool



Integrated Care [IC] –Level 1

Who: Other AAAs serving IC demonstration region

Service Providers

Why: Need to present “single” package to health plan

Need vehicles for increased capacity

Interagency Care Team [ICT] - Level 2

Who: AAA, FQHC, Hospital, Health Dept.

Designed to expand to other entities on Community Roadmap

Why: AAA – transitions coaching; linkage to HCBS; ongoing CM

FQHC – PCP; care coordination

Hospital – Identification of all initial patients; coordination w/ hospitalists, other physician groups

Health Dept. – outcome analysis; data tracking


Value Expectations…

Integrated Care [IC] –Level 1

  • Cost-effective service network for HP
  • Person-centered approach for consumers
  • Structural partnership between aging network and medical systems
  • Expanded development of HCBS system
  • Expansion of consumer training/empowerment

Interagency Care Team [ICT] - Level 2

  • Reduced hospitalizations
  • Better health outcomes for targeted high risk patients/consumers
  • Less duplication & fragmentation of effort
  • Development of “bundled” payment model for scalability
  • Recognition of merit of AAA product as valued for ACO, PCMH development


Integrated Care [IC] –Level 1

  • Scalable service delivery
  • Assumption of risk [under discussion]
  • Commitment to refining system as needed; development of new AAA direct services
  • Creation of legal partnerships w/ otherAAAs for efficient geographic response

Interagency Care Team [ICT] - Level 2

  • Reduction of ED use & hospitalizations; cost reductions
  • Better health outcomes for some diagnoses
  • Consumer empowerment - patient survey
  • Creation of replicable model
  • Initial redirection of staff time making ICT a priority

Advice/lessons learned…

Integrated Care [IC] –Level 1

  • Must let go of pre-established terminology and processes
  • Shift to a “business only” model
  • Need to improve/scale up data tracking and analysis
  • Must combine new pricing strategies with volume expectations for negotiations & sustainability

Interagency Care Team [ICT] - Level 2

  • Need to build on relationships
  • Approach from consumer perspective; recognize where work/goals intersect
  • Use reality that major systems have great services but operate in functional isolation, often seeing the same person
  • Creating a Community Roadmap of the range of services available to and used by consumers helped give perspective

Developing Service Packages

that appeal to healthcare entities of

various sizes, shapes and motivations

June Simmons, CEO

Partners in Care Foundation

Presented to N4A, February 20th, 2014


Partners in CareWho We Are

Partners in CareWho We Are

Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care

We address social and environmental determinants of health to broaden the impact of medicine

We have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhanced patient self-management

Changing the shape of health care

through new community partnerships

and innovations


1% spend 21%

5% spend 50%

The Upstream Approach: What would happen if we were to spend more addressing social & environmental causes of poor health?


Healthcare’s Blind Side

  • 2011 RWJF surveyof 1,000 primary care physicians
    • 85%: Social needs directly contribute to poor health
    • 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care
    • 1 in 7 prescriptions would be for social needs
    • Psychosocial issues treated as physical concerns
  • This is the gap we fill…our value to patients and the healthcare system
why should cbos be part of the healthcare system
Why should CBOs be part of the healthcare system?
  • To thrive, CBOs need to play a new role connecting the home with the healthcare system
    • Home provides unique perspective otherwise unavailable to healthcare providers.
    • Quality measures for health plans and providers relate to issues such as medication use and fall prevention – HEDIS, Medicare Advantage Star Ratings
    • Meds are major factor in readmissions (72%)
    • New focus on population health – identifying and proactively addressing health for high-risk patients
healthcare hcbs better health lower costs
Healthcare + HCBS = Better Health, Lower Costs
  • We address social determinants of health
    • Personal choices in everyday life
    • Isolation, Family structure/issues, caregiver needs
    • Environment – home safety, neighborhood
    • Economics – affordability, access
  • Lower cost structure, high impact, evidence based
  • We help identify where interventions will have greatest impact:
    • Population health management – prevention
    • Managing progression of chronic conditions & function
    • Medication management
    • Reducing admissions/readmissions & SNF
    • Late life care – palliative/hospice

Targeted Patient Population Management with

Increasing Disease/Disability


HCBS in Active Population Management – Value

Propositions: Who Pays and Who Saves?

25% of all Medicare is Last Year of Life: Duals Plans; Medicare Advantage SNP; ACO/MSSP





Nursing Home Diversion for Duals Plans

Care Transitions


Safety Assessment

ED/Hosp: Capitated Providers/Plans

Readmission penalties: Hospitals

EB Self-Management:

CDSMP/DSMP; MOB; Healthy IDEAS; EnhanceFitness; PEARLS; Fit & Strong

Chronic Disease Management:

Duals Plans; MA SNP

Prevention: MA Plans; Capitated Med Groups

Senior Center – meals, classes, exercise, socialization

contact us
Contact Us

June Simmons, CEO

Partners in Care Foundation

732 Mott St., Suite 150, San Fernando, CA 91340

Main #: 818.837.3775

[email protected]