An Innovative Care Management Model for People with Disabilities

1. An Innovative Care Management Model for People with Disabilities 2013 Age & Disabilities Odyssey Conference Jeri Peters, Chief Nursing Officer June 18, 2013 French River 1, City Side

2. Objectives • Participants will learn about UCare’s experience in designing a care model. • Participants will gain an understanding of how a stratification process can be utilized to manage rapid enrollment of a large group of individuals with disabilities. • Participants will understand UCare’s lessons learned about this new care model and how to work effectively with internal and external care managers.

3. Our Mission UCare will improve the health of our members through innovative services and partnerships across communities.

4. About UCare Founded in 1984 by faculty in the Department of Family Medicine and Community Health at the University of Minnesota Initiated to ensure family medicine residents would have a clinic setting to complete residency program Started as demonstration project serving 100 people; today, UCare is Minnesota’s fourth-largest health plan with more than 300,000 members Committed to serving Medicaid and Medicare beneficiaries with innovative, high-quality health care programs and services

5. Serving Minnesotans Statewide

6. Current Membership • 323,270 members – 05/2013 • 150,449: Medical Assistance • 35,099: MinnesotaCare • 3,081: Minnesota Senior Care Plus • 19,189: SNBC (Disability) • 9,549: MSHO (SNP) • 88,487: Medicare (Minnesota) • 6,968: Medicare (Wisconsin) • 10,448: Supplement & ASO

7. Member Demographics UCare serves a culturally diverse mix of over 300,000 members PMAP MnCare State Public Prog. Caucasian 35% 69% 43% African origin 30% 12% 26% Asian origin 19% 9% 17% Hispanic (all origins) 11% 4% 9% Native American 2% 1% 2% Other 3% 5% 3%

8. Our Employees are Diverse CAUCASIAN – 79% BLACK or AFRICAN AMERICAN – 9% ASIAN – 8% TWO or MORE RACES – 2% HISPANIC – 1%

9. UCare’s Approach to Managed Care Program flexibility and support services tailored to individual needs 40% consumer representation on Board of Directors; three member advisory committees Expertise in cooperative work with federal, state, and local governments, and community partners Innovative risk and service partnerships with care systems and providers

10. Getting Started Created a workgroup of social workers, nurses, disability experts and physicians Reached consensus agreement on definition of care coordination Established a set of guiding principles to build our model around Selected core model structure Defined key requirements & assumptions Reviewed contractual obligations Analyzed internal & external resources

11. Care Coordination "Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care." AHRQ: Care Coordination Measures Atlas, Chapter 2

12. Standard Care Models

13. UCare Connect Basics Special Needs Basic Care (SNBC) program designed by the Minnesota Department of Human Services (DHS) Be at least 18 years old and under age 65 Be eligible for Medical Assistance Must have a certified physical disability, developmental disability, and/or mental illness Medicaid eligible, however may have dual coverage

14. Guiding Principles • High-touch processes that build relationships with members • Efficient processes that would work with many members quickly • Community partnerships • Sustainable financial and staffing models • Must meet payer & regulator requirements • Include the Triple Aim concept • Needed to build model that would evolve over time

15. Key Assumptions • Input from members was critical to model development • Feedback from providers and delegates will be incorporated • Members have variable needs for support and needs vary over time • Case management resources in local communities know members and offer good services • Behavioral health issues affect many SNBC members

16. Model Construction Began with minimal clinical and utilization information Conducted a literature search Consulted with experts Evaluated past experience with MnDHO Outlined DHS contract requirements for care model Reviewed Medicare model of care requirements & structure Built a stratification process

17. UCare Connect Care Model Designed to provide support and assistance to help individuals navigate complex health systems Based on a well accepted risk analysis and case management identification tool Members are stratified and assigned a risk score Offers five care management options based on risk score/health needs Collaborate with counties and lead agencies on long-term care benefits Care coordination provided by both external (delegates) and internal staff Utilizes a combination of field & telephonic staff Service area consists of 41 counties in Minnesota UCare manages the Medicaid benefits (effective 2012)

18. UCare Connect Care Model • All members are stratified based on business rules • All members are assigned a Care Navigator who may assist the member in: • Accessing preventive care • Establishing a primary care provider • Making referrals for other services as needed • All members receive a welcome call from Member Services to: • Help UCare better understand the member’s health care needs • To promote the member’s engagement in their care • All members are offered a Health Risk Assessment (HRA) within 30 days of enrollment • Model is designed to allow members to move along a continuum of care • Unique, sophisticated model based on limited data using a validated risk grouper

19. Stratification: An Innovative Approach Inputs Business Rules Business Rules Business Rules Business Rules Outputs

20. Data Source Extracts / Data Processing Data Outputs

22. Clinical stratification based on interventions/care needs All members are stratified initially and then restratified on a quarterly basis Establishes initial Case Management Index Score Member Stratification

23. Stratification Levels

24. Different Needs, Different Care Management Options All members, plus those with low-level needs: Surveillance We need more information or assurance that member’s needs are being met… Care Navigator Follow-up Member needs high-level assessment… Team Review Recent hospitalization or serious medical illness… Complex Case Management Member is likely to have significant ongoing care needs (medical or behavioral)… Delegated Case Management

25. Different Needs, Different Care Management Options Care Navigator Designated employee whose primary focus is to support and assist the member. Works with county social workers, medical and mental heath professionals, and other community programs. Assists members in accessing medical, mental health, and chemical dependency services. Assists members in accessing other benefits.

26. Different Needs, Different Care Management Options Team Review Includes medical director, navigator, and care manager. Use structured discussion tool and HRA summary. Goal is to disposition the case. Up to 50+ reviews in ~ 90 minutes. 598 reviews completed through June.

27. Different Needs, Different Care Management Options • Acute Medical Case Management • Focus on short-term, episodic care coordination. • Provide condition specific education. • Assist with arranging home care services, etc. • Transition Management • Focus on admission and/or readmissions. • Members have acute chronic needs. • Make referrals to community resources. Complex Case Management Two types:

28. Different Needs, Different Care Management Options Delegated Case Management • Contracts with community agencies and counties. • Delegates have expertise in serving adults with disabilities. • Members assigned to delegated case management receive: • Face-to-face assessment. • Comprehensive plan of care. • Quarterly check-in with case manager.

29. Different Needs, Different Care Partners

30. Different Needs, Different Care Partners • Counties: Chippewa, Lac Qui Parle, Faribault, Martin, Mille Lacs, Olmsted, Pine, Sherburne, Stearns • Community Agencies: AXIS Healthcare, Brain Injury Assn – MN, BlueStone Physicians, Mental Health Resources *, Minnesota Visiting Nursing Agency*, South Metro Human Services, The Guild, Lutheran Social Services** • Medical Services: > 7,000 primary care providers, >15,000 specialty providers, medical homes where available • Long-term care providers: collaborate with counties for PCA, PDN, and waiver services • Health Plan: Care Navigators, Benefits Specialists, TOC Management *Complex case management ** legacy members

31. Key UCare Connect Member Benefits No premiums or co-pays Dental benefit includes UCare’s See-A-Dentist Guarantee℠, UCare’s Mobile Dental Clinic, and DentaQuest’s network providers Transportation through UCare’s Health Ride for all eligible members, including those who need to see providers located outside of their county of residence Free monthly membership at a SilverSneakers®-participating fitness club Fitness kit with tools and information to help improve fitness at home A second dental cleaning and exam each year

32. UCare Connect Clinical Advantages • Disease management: • Members have access to disease management programs for asthma, diabetes and heart failure • Health and wellness: • Members have access to all of UCare’s health and prevention programs, including annual check-ups, maternity care, fitness programs • Health risk assessments: • The assessment is designed for individuals with physical disabilities, developmental disabilities, and behavioral health disabilities • Offered online in multiple languages

33. Measuring Health Outcomes HEDIS scores CAPHS/HOS surveys Internal clinical & quality indicators:

34. Lessons Learned • Member-centric, holistic care is the focus • It takes a team • Members • Families/ significant others • Both internal & external care management partners • Primary care providers • Regulators & payers • Active, Interdisciplinary Care is critical • Integrate care strategies are organized around the members need • Ongoing, close collaboration with providers and care givers to coordinate all aspects of medical, behavioral, social, spiritual, and community needs • Team composition and respective roles are based upon member needs and practice capacity

35. Lessons Learned • There is no gold standard care model • It depends on the needs of your members • It depends on your local circumstances • It depends on your goals • Positive health outcomes • Client satisfaction • Cost containment • Building a model with multiple subsets requires a high degree of flexibility. • Partner closely with providers & community agencies. • The only constant in care management is the member.

36. Member Stories Judy “I keep losing track of time and don’t remember how I got places” Ralph & Mary A couple with Diabetes Mike “I need a dentist”

37. For More Information Jeri Peters Chief Nursing Officer, UCare japeters@ucare.org 612-676-3655