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Medicaid Redesign Proposals - PowerPoint PPT Presentation


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Supportive Housing Network September 23, 2011. NYSDOH submitted two draft SPAs to CMS on June 30, 2011 One SPA targeted the Managed Long Term Care population; the other targeted the chronic medical/behavioral health population

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supportive housing network september 23 2011
Supportive Housing Network

September 23, 2011

slide2

NYSDOH submitted two draft SPAs to CMS on June 30, 2011

  • One SPA targeted the Managed Long Term Care population; the other targeted the chronic medical/behavioral health population
  • The focus of today will be on the SPA targeting the chronic medical/behavioral health population
  • Available on the NYSDOH Health Home Website at:

http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm

slide3

At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition.

Chronic conditions  include but are not limited to:

  • mental health condition
  • substance abuse disorder
  • asthma
  • diabetes
  • heart disease,
  • being overweight (BMI over 25)
  • HIV/AIDS
  • Hypertension
slide4

Enrollees in the behavioral health category will be identified through claims and encounter data. They often have co-morbid chronic, medical conditions and unmet social needs such as a lack of permanent housing

  • Enrollees in the chronic medical condition category will be identified through claims and encounter data as having two or three chronic medical conditions – including HIV/AIDS.
  • The State will use a combination of clinical risk groups (CRG), an algorithm that predicts hospitalizations, and behavioral health indicators to select Medicaid enrollees for health homes.
slide5

Total Complex

N=976,356

$2,338 PMPM

32% Dual

51% MMC

$25.9 Billion

slide6

“Medical Home” for Patients with Risk Score ≥50

Based on Prior 2-Years of Ambulatory Use

51%

Source: NYU Wagner School, NYS OHIP, 2009.

slide7

NY will use “designated providers” for the Health Home Program

  • Designated providers can be:
    • Managed Care Plans
    • Hospitals
    • Medical, mental and chemical dependency treatment clinics
    • Federally Qualified Health Centers (FQHCs)
    • Targeted Case Management (TCM) programs
    • Primary care practitioner practices
    • Patient Centered Medical Homes (PCMHs)
    • Any other Medicaid enrolled entity that meets NY’s health home requirements
    • Considering adding other long term care providers
slide8

Section 2703 of the Patient Protection and Affordable Care Act (ACA) provides states, under the state plan option or through a waiver, the authority to implement health homes.

  • opportunity to address and receive additional federal support for the enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and long-term services and supports for persons with chronic illness.
  • provides 90 percent FMAP rate for health home services for the first eight fiscal quarters that a health home state plan amendment is in effect; multiple SPAs permitted.
slide9

NY is seeking applicants that :

    • have strong medical, behavioral, and social service community providers connections
    • use multi-disciplinary teams of medical, behavioral , TCM, and social services providers that can assure appropriate and timely access to services.

Each patient enrollee will be assigned a single care manager who is responsible for managing and coordinating their care. There will be only one care plan for each patient enrollee. All members of the health home team will report back to the care manager on patient status, treatment options, actions taken, and outcomes.

Health homes will be responsible for reducing or eliminating costs associated with avoidable inpatient and emergency room visits and improving patient outcomes.

slide10

Must be enrolled (or be eligible for enrollment) in the NYS Medicaid program and agree to complywith all Medicaid program requirements.

  • Can either directly provide, or subcontract for the provision of, health home services. Responsible for all health home program requirements, including services performed by the subcontractor.
  • Care coordination and integration of heath care services will be provided to all health home enrollees by an interdisciplinary team of providers, where each individual’s care is under the direction of a dedicated care manager who is accountable for assuring access to medical and behavioral health care services and community social supports as defined in the enrollee care management plan.
  • Must meet standards for delivery of six core health home services as described in following slides. Must provide written documentation that clearly demonstrates how the requirements are being met.
slide11

Health home providers will be required to provide the following health home services in accordance with federal and State requirements:

    • Comprehensive care management
        • An individualized patient centered care plan based on a comprehensive health risk assessment – must meet physical, mental health, chemical dependency and social service needs.
    • Care coordination and health promotion
        • One care manager will ensure that the care plan is followed by coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee’s needs. The health home provider will promote evidence based wellness and prevention by linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services based on need and patient preference.
    • Comprehensive transitional care
        • Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care.
    • Patient and family support
        • Individualized care plan must be shared with patient enrollee and family members or other caregivers. Patient and family preferences are considered.
slide12

Health home providers will be required to provide the following health home services in accordance with federal and State requirements:

    • Referral to community and social support services
        • Provider will identify and coordinate community and social supports
    • Use of health information technology (HIT) when feasible
        • Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation
slide13

NY will be using quality measures that fall into the following categories:

    • Measures collected from claims and encounters
    • Measures currently collected by managed care plans
    • Measures per NQF and/or meaningful use measures
    • New measures that meet federal reporting requirements
    • Referral to community and social support services
        • Provider will identify and coordinate community and social supports
    • Use of health information technology (HIT) when feasible
        • Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation
slide14

976,000+ high cost/high need Medicaid enrollees

(1) Chronic conditions at risk for a 2nd chronic condition

(2) Chronic conditions

(1) Serious & Persistent Mental Health Condition

*Medically and Behaviorally Complex

Non-Compliant with Treatment Health Literacy Issues

ADL Status

Inability to Navigate Health Care System

Social Barriers to Care

Homelessness

Temporary Housing

Lack of Family or Support System Food , Income

Need assistance applying for Entitlement Programs

Yes

Patient Meets Health Home Criteria

Assigned a Health Home

Patient Assessment*

Level I Health Home Services – Moderate Need

Level II Health Home Services – Multiple Complex Needs

Level III Health Home Services – Intensive Complex Needs

Periodic Reassessment *for continuation of Health Home Services

Primary Care Practitioner Manages

Health Home Services Not Required

slide15

Medicaid Agency

Contract with HHs

MCO/

BHO

HH

Recipient

Recipient

HH

Recipient

Recipient

Recipient

PCMH

MCO/

BHO

Recipient

CMHC

Recipient

Other

Recipient

MCO plus provider = HH

Recipient

MCO/BHO/ACO is HH

Recipient

Recipient

Recipient

slide16

The State will use a combination of the following to assign Medicaid enrollees to Health Homes:

    • clinical risk groups (CRG),
    • an algorithm that predicts hospitalizations, and
    • behavioral health indicators
  • Medicaid enrollees will be assigned to a health home, to the extent possible, based on existing relationships with ambulatory, medical and behavioral health care providers or health care system relationships, geography, and/or qualifying condition.
  • Initial assignments will be for members who qualify for Health Home services but currently do not have a meaningful primary care or case management connection.
  • Patients will not be moved from their current TCM/COBRA, CIDP, MATS
slide17

The State will also include any supportive housing services an individual may have in keeping those connections in health home assignments.

Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment.

The State will provide health home providers a roster of assigned enrollees and current demographic service access information to facilitate outreach and engagement.

With the exception of TCMs, where special arrangements may be made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data provided by the state.

slide18

165 LOIs received

    • Many comprehensive well thought through networks
    • Some concerns about specific network adequacy issues
    • Some LOIs have more comprehensive networks than others
    • Some overlapping regions and partners
    • Some smaller less robust entities that should merge
  • DOH is working with OMH, OASAS and NYCDOHMH to assess network adequacy and suggest additional network partners and any appropriate mergers
slide19

Phasing in Health Home Implementation:

  • Phase I -13 counties
    • Applications due November 1
    • Implementation January, 2012
  • Phase II – Counties TBD
    • Target Implementation April, 2012
  • Phase III-Counties TBD
    • Target Implementation June, 2012
slide20

Bronx

Brooklyn

Nassau

Monroe

Warren

Washington

Essex

Hamilton

Saratoga

Clinton

Franklin

St. Lawrence

Schenectady

slide21

Finalizing roles of responsibilities for managed care plans

Targeted Care Management transition

Timing and counties in phases II and III

Network adequacy review and feedback

Final CMS SPA roles (outreach and engagement; quality measures)

Rate adequacy feedback (HIV upweights, etc.)

slide22

Housing is one of the key determinants in identifying a member’s need for care coordination

  • Opportunity for the medical community and supportive housing community to work more collaboratively.
  • Some Medicaid members in supportive housing will be eligible for Health Home services.
  • Similar to members in TCM, supportive housing is providing effective and comprehensive care coordination services.
slide23

More formal arrangements between supportive housing providers and direct service providers to assure care coordination is tethered to direct care services.

  • Both the supportive housing community and the medical (both physical and behavioral health) community can work towards identifying additional resources for housing and increase housing opportunities
  • Members in supportive housing eligible for Health Home services can be assigned to Health Homes that include their supportive housing as a partner.
slide24

Improved patient health outcomes

  • Reduce inappropriate ED visits
  • Reduce avoidable hospital admissions and readmissions
  • Achieve a ROI and ultimate cost savings

Increasing the number of publicly insured members will only be possible if we create a sustainable system

slide25

Speed at which the program is getting launched

    • Addressing some of that with the phased implementation
  • Lack of housing slots
  • Effectuating change at the site of service delivery
  • Bringing care coordination closer to service delivery
slide26

NYS Health Home Web site (links to many relevant materials): http://nyhealth.gov/health_care/medicaid/program/medicaid_health_homes/index.htm.

  • Questions and/or comments regarding New York\'s implementation of health homes can be directed to [email protected]
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