Pamela Parker Special Needs Purchasing Minnesota Department of Human Services

1. Care Coordination for the Chronically Ill:Minnesota Senior Health OptionsAlliance for Health Reform BriefingAugust 11, 2011 Pamela Parker Special Needs Purchasing Minnesota Department of Human Services pam.parker@state.mn.us

2. Medicaid Managed Care For Chronically Ill in Minnesota • Minnesota SeniorCare Plus (MSC+): Mandatory enrollment for 65+ including dual eligibles statewide in all settings and levels of care. Began in 1983. Includes Medicaid primary, acute and long term care services, contracts with 8 Medicaid plans. Medicare is fee for service. 11,500 enrollees. • Minnesota Senior Health Options (MSHO): Fully integrated Medicare/Medicaid program, voluntary enrollment as alternative to MSC+ for dual eligibles 65+, statewide in all settings and levels of care. Highly integrated primary, acute and long term care services, contracts with Medicare Advantage Dual Eligible Special Needs Plans (SNPs) sponsored by the 8 MSC+ plans. 37,000 enrollees • Special Needs BasicCare (SNBC): Voluntary enrollment for people with disabilities 18-64, includes Medicare and Medicaid primary, acute and behavioral health services including all mental health case management, most long term care is carved out, delivered through 4 SNPs and 1 Medicaid only plan, 6,000 enrollees, now expanding statewide under new legislation

3. Minnesota Senior Health Options • MSHO enrolls 70% of Minnesota’s Medicaid seniors and attracts the largest proportion of seniors with long term care needs • MSHO primarily enrolls dually eligible seniors who already have high chronic disease rates and multiple chronic conditions • Average age of members is about 81 • 72% of MSHO members require long term care services • 30% reside in nursing homes (most are residents prior to Medicaid eligibility) • 42% receive home and community based services • 28% are community non-frail • Dementia rates are more than 3 times greater for nursing home residents than for those served in community settings • Aligned integrated full risk financing from both Medicaid and Medicare under MSHO provides incentives for managed care organizations to improve care coordination strategies across all services and care settings • Addition of Medicare through SNP contracts enables more intensive models of care coordination compared to non- integrated programs (MSC+)

4. MSHO Care Coordinator Functions • All members are assigned an individual care coordinator (Nurse Practitioners (NPs) RNs, Social Worker (SW) ) • Care Coordination models blend social and chronic care management approaches across all services • Care Coordinators conduct risk assessments, monitor chronic conditions and transitions, facilitate annual primary care visits, communication with physicians and preventive care, and authorize home and community based services • Care Coordinators provide referral and coordination with disease and medication management programs • Care Coordinators also implement system wide quality improvement programs/interventions • SNPs provide data to care coordinators to follow up on specific member chronic care needs (eg diabetes or CHF care)

5. Many Flowers Bloom: Multiple Care Models • Clinic Care Systems: (may also be Health Care Homes) capitated or virtual caps with gain/risk sharing, includes MD teamed with NP and SW • SNP Care Coordination: SNP based care coordinators assigned to work with a clinic or group of clinics in their network • Care Management Organizations: SNP contracts with community or provider organizations serving specialized populations (behavioral health, people with disabilities, or immigrant groups) • SNP Contracts with County Social Services: especially used in rural areas • Health Care Homes: SNPs required to cover payment as a Medicaid service, MN is an all payer HCH state

6. Reality Check • Goal is to provide increased incentives for Total Cost of Care/HCH models to reform provider service delivery • But Total Cost of Care and NP models are difficult to implement statewide due to lack of provider capacity or interest • SNPs must also rely on existing resources (county social services, community organizations, clinics, behavioral health) to meet total medical/social needs • SNPs have built increased chronic care management into county social service care coordination contracts • Goal is to build more formal communications linkages between HCH and community social services care coordination functions • As more HCH are certified, SNPs may facilitate blending of county social service models with HCH

7. MSHO Results • MSHO satisfaction highest of all state managed care programs, dis-enrollment is very low • MSHO has increased access to community services, shows reductions in expected use of nursing homes, and community services PMPM costs are less than forecasted • 98% of MSHO seniors have annual primary care visits. • MSHO shows reduced hospitalization rates for Ambulatory Care Sensitive Conditions (ACSC) for asthma, bacterial pneumonia, congestive heart failure, dehydration and diabetic complications between 2006-2009 (most recent data available). • Numerous performance improvements for seniors have been implemented system wide • All MN SNPs scored 100% on CMS Structure and Process measure related to integration for 2010. • 7 of 8 MN SNPs scored 4 or above on the CMS MA Star Ratings

8. Where We Need to Go • New ACA pathways for aligned financing for dual eligibles provide exciting opportunities for building platforms that improve chronic care coordination! • Medicare, rather than Medicaid, should cover HCH payments for dual eligibles since Medicare is primary for physician services. • Medicare risk adjustment appears problematic  for Dual SNPs designed for people <65 with disabilities. Several MN Medicaid plans had to drop their Medicare SNPs for that group when the Medicare bid process resulted in premiums that dual eligibles cannot pay.  Medicare risk adjustment needs to better capture costs for SNPs specializing in serving people with disabilities and the bid process needs revamping for  Dual SNPs. • The ACA provision for frailty adjustor for FIDES SNPs also needs revision. MN SNPs don’t qualify because the State requires them to enroll community non-frail members. • Need flexibility for States to de-link service and eligibility tiers between institutional and community based care to improve targeting of care and services.

9. CASE STUDIES(A Few Examples of Many Care Coordination Strategies Being Used by MN D-SNPs)

10. Use of Aligned Financing • MSHO SNP authorizes additional Intensive Service Day payment to nursing home for 70 year old resident who needs highly intensive rehabilitative care, wheel chair bound, ventilator dependent, and post polio with tracheotomy and wound care. This reduces need for additional hospitalizations. • SNP provides regular check in by Care Coordinator with nursing facility to monitor care. • At first resident is expected to remain in nursing home long term because of dependence on vent so after 100 day Medicare stay is over, SNP pays for nursing home care under Medicaid managed care custodial care benefit. • Resident becomes more motivated to wean from vent and return home. • Additional respiratory therapy provided reduces need for ventilator. • Care Coordinator develops Community Support Plan for return home. • Community based services are arranged (ramp, home health aide and RN visits, Lifeline). • About six months after entering nursing home, resident returns home with more control over managing health and independence. • This case study is courtesy of Blue Plus • Other health plans also have similar case studies

11. Medication Therapy Mgmt (MTM) Project • Sponsored by Medica with QIO Stratis Health, expanded to include other MN Dual-SNPs • Goal: Reduce potentially inappropriate medication (PIM rates and Drug-Drug Interaction (DDI) rates for MSHO members. • Interventions: • Pharmacist medication review and member education • Pharmacist to provider- recommend changes • Care coordinator training and education on MTM with care coordinator referral to an MTM pharmacist • Care Coordinator training and education on drug safety (list of common PIMs and DDIs) • Medical Director Support • Results: on track to exceed goal of 3% reduction