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SCDuE South Carolina Dual Eligible Demonstration. Integrating Care for Medicare-Medicaid Enrollees Tuesday, October 15, 2013 4pm. Presenters: Teeshla Curtis, Program Manager; Sam Waldrep, Senior Consultant; and Dr. Michael Musci. GOALS FOR THIS SESSION.

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scdue south carolina dual eligible demonstration
SCDuESouth Carolina Dual Eligible Demonstration

Integrating Care for Medicare-Medicaid Enrollees

Tuesday, October 15, 2013

4pm

Presenters: Teeshla Curtis, Program Manager;

Sam Waldrep, Senior Consultant; and

Dr. Michael Musci

slide2
GOALS FOR THIS SESSION

To provide an overview of the South Carolina Department of Health and Human Services’ (SCDHHS) South Carolina Dual Eligible Demonstration (SCDuE)

To describe how the Demonstration aligns with South Carolina’s health reform strategies for clinical integration

slide4
HISTORY

Medicare and Medicaid programs signed into law July 30, 1965

1965 “three-layer cake” – Medicare Part A hospital services; Medicare Part B physician and other outpatient services; and Medicaid expanding federal support for health care services for poor elderly, disabled, and families with dependent children

Not initially designed to integrate and coordinate services for individuals served by both program

slide5
HISTORY

During the first year of Medicare, superior health care has been provided for millions of aged Americans, and health standards have been raised for all Americans. This has come about because of cooperation between the federal government, physicians, insurance carriers, and the states. It would not have been possible without the strong support of each of these groups. We have forged a partnership for a healthier America.

Statement By the President on the First Anniversary of Medicare – July 1, 1967

slide6
DUAL ELIGIBLES

10.2 million Americans are eligible for Medicare and Medicaid (known as Medicare-Medicaid enrollees or “dual eligibles”)

7.4 million are “full duals”

17.7% increase, from 8.6 million to 10.2 million between 2006 and 2011 (One in five Medicare enrollees)

In comparison, the number of Medicare-only beneficiaries grew by only 12.5%

Sources: Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2011, Prepared by Medicare-Medicaid Coordination Office, February 2013.

slide7

The face of South Carolina’s Medicare-Medicaid enrollees 65+ is:

75% Female51% African-American1-2 chronic conditionsMost common conditions: diabetes and heart disease75% not using LTSS

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

slide8
STATE PROFILE

Chronic Disease Prevalence by Enrollment Group

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

slide9

FULL BENEFIT MEDICARE-MEDICAID ENROLLEES’ USE OF FEE-FOR-SERVICE MEDICAID-FUNDED LTSS

Source: Centers for Medicare & Medicaid Services. (n.d.). Medicare-Medicaid enrollee state profile. Retrieved from http://www.integratedcareresourcecenter.com/PDFs/StateProfileSC.pdf

slide10
PURPOSE OF SCDUE

This Demonstration will provide a new health care option for South Carolina’s seniors with both Medicare and Medicaid. This program will make it easier for Medicare-Medicaid enrollees to receive all Medicare and Medicaid services through a single entity that is accountable for the quality and cost of these services.

The Demonstration proposes:

  • To integrate and coordinate care for beneficiaries with both Medicare and Medicaid; and
  • To purchase quality health outcomes through a person-centered model that delivers care at the right time and in the most appropriate setting.
slide11
PURPOSE OF SCDUE

Goals

  • Improve health outcomes
  • Delay the need for nursing facility care
  • Reduce avoidable emergency department visits and hospital readmissions
  • Increase access to home and community based services

Covered Services

  • Medicaid services, including:
      • Behavioral health
      • Home and community based services
      • Nursing facility services
  • Medicare services, including:
      • Primary and acute care
      • Part D (prescription drugs)
      • Skilled nursing facilities
slide13
STATUS UPDATE

The SCDuE team is in the process of finalizing the Memorandum of Understanding (MOU) between the State and CMS.

The MOU will outline the operational details of the Demonstration including changes the State has incorporated since the initial submission of its proposal in May 2012.

Participating health plans will be selected later this fall.

slide14
Healthy Connections Mission:…to purchase the most health for our citizens in need at the least possible cost to the taxpayer.
health reform in south carolina
Health Reform in South Carolina

3 Pillar Strategy

Clinical

Integration

Payment

Reform

Hot Spots

&

Disparities

slide19
“At the core of our mission are seniors and persons with living disabilities.”- Anthony Keck, SCDHHS Director
slide20
CURRENT SYSTEM

Fragmented

Not Coordinated

Complicated

Difficult to Navigate

Not Focused on the Individual

Gaps in Care

https://msp.scdhhs.gov/scdue/

slide21
INTEGRATED CARE

One set of comprehensive benefits: primary & acute care , prescription drug, and long-term supports and services

One ID card

Single and coordinated care team

Health care decisions based on beneficiary needs and preferences

Provide flexible, non-medical benefits that help individuals stay in the community

slide22
PERSON-CENTERED

Improve both the quality of care and the quality of life

Foster patient-provider communication and relationships

Enhance health literacy to support informed decision making

Participant’s strengths, capacities, preferences, and personal outcomes are identified and documented

slide23
PERSON-CENTERED

I decide where and with whom I live.

I make decisions regarding my supports and services.

I work or do other activities that are important to me.

I have relationships with family and friends I care about.

I decide how I spend my day.

I am involved in my community.

My life is stable.

I am respected and treated fairly.

I have privacy.

I have the best possible health.

I feel safe.

I am free from abuse and neglect.

Source: (Ingram, 2013). Integrated Care

Transformation: State Accomplishments, Challenges and

Opportunities for the Future [PowerPoint Slides].

Improving New Systems of Innovation for Dual Eligibles.

slide25
CARE COORDINATION

Patient Center Medical Home model, lead by primary care provider

Multidisciplinary team structure with provider input and/or direct involvement

Transition planning (e.g., transitions between acute care settings and the community or nursing facilities)

Bi-directional communications between health plans and providers

Person-centered approach

slide26
CARE COORDINATION

Universal Assessment Tool

Individualized care plan involving participant and/or her caregiver

Designated care coordinator linking participant, PCP, family/caregiver ensuring care coordination and the communication of barriers and needs

slide27
CARE COORDINATION

Access to a single, toll-free point of contact for all questions;

Development of an Individualized Care Plan that is periodically reviewed and updated;

Disease self-management and coaching; and

Medication review, including reconciliation during transitions of care setting.

slide29
RATE STRUCTURE

Blended capitation rate: Medicare Part A, Part B, Part D, Medicaid

Medicaid Rate Cells

  • Nursing Facility
  • Home and Community Base Services Plus
  • Home and Community Base Services
  • Community
slide30
PAYMENTS

Provider reimbursements negotiated by provider with contracted health plans

Pay for Performance

Care transition related incentives

Reimbursements should not be identical to FFS model

Shared goals based on outcomes

slide32

Overview & Background

The Henry J. Kaiser Family Foundation. (2013, August 1). State demonstration proposals to integrate care and align financing for dual eligible beneficiaries. Retrieved from http://kff.org/medicaid/fact-sheet/state-demonstration-proposals-to-integrate-care-and-align-financing-for-dual-eligible-beneficiaries/

slide33
ELIGIBILITY OVERVIEW

Demonstration population inclusion criteria:

  • Individuals 65 years and older
  • Full-benefit dual eligible
  • Individuals receiving Home and Community Based Services (HCBS) waivers (i.e., HIV, Vent, and Community Choices)

Excluded populations (at time of enrollment):

  • Residing in a nursing facility;
  • Enrolled in hospice;
  • Receiving End-Stage Renal Disease (ESRD) services;
  • Enrolled in a Program of All-Inclusive Care for the Elderly (PACE); or
  • Enrolled in Department of Disabilities and Special Needs (DDSN) operated waiver serving adults (ID/RD, HASCI, and Community Supports).

Enrollment includes an opt-in period following by passive enrollment. The Demonstration is voluntary; beneficiaries can opt-out as well as change plans at any time.

slide34
ENROLLMENT

Opt-in statewide enrollment:

July 1, 2014 - December 31, 2014

Passive enrollment:

Wave 1 – January 1, 2015

Wave 2 – March 1, 2015

Wave 3 – May 1, 2015

slide35
NEXT STEPS

Signing of MOU

Release of Demonstration name

New SCDuE website launch

Provider forums – November 2013

Start of Readiness Review Process

slide36
NEXT STEPS

Integrated Care Workgroup Meeting

Thursday, October 17

10am – 12noon

Lexington Richland Alcohol and Drug Abuse Council (LRADAC)

2711 Colonial Drive, Columbia, SC 29203

slide39
CONTACT INFORMATION

Nathaniel J. Patterson, MHA

Director, Health Services

SC Dept. of Health & Human Services

1801 Main Street

Columbia, SC 29201

(803) 898-2018 | Office

(803) 255-8209 | Fax

[email protected]

________________________________

SCDuE Website

https://msp.scdhhs.gov/scdue/

Teeshla Curtis

SCDuE Program Manager

SC Dept. of Health & Human Services

1801 Main Street

Columbia, SC 29201

(803) 898-0070 | Office

(803) 255-8209 | Fax

[email protected]

________________________________

SCDuE E-mail Address

[email protected]

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