Home Care Provider WebinarJune 2014 HSPRE0005-0614
Introduction Welcome to the quarterly Home Care Provider Webinar • These webinars are open to all Connecticut Medical Assistance Program (CMAP) enrolled home health care providers and serve as a platform to optimize collaboration, identify opportunities to streamline and improve processes, and optimize quality of care. • You are encouraged to use the Home Care Provider Forum email box at HCProvForum@chnct.org to forward your questions regarding information provided at these forum meetings or to share recommendations for future Home Care Provider Forum agenda topics. • Please feel free to share your thoughts and ask questions at the end of today’s presentation.
Home Health Metrics Calendar Year 2013
CY 2013 Home Health Authorization Requests by Service Type Authorization Service TypeApproved DeniedPartial DenialTotal Complex Nursing 826 (88.91%) 15 (1.61%) 88 (9.47%) 929 Home Health Aide 1,804 (94.01%) 16 (0.83%) 99 (5.16%) 1,919 Home Health Therapy 634 (96.35%) 7 (1.06%) 17 (2.58%) 658 Medication Admin 4,966 (96.77%) 5 (0.10%) 161 (3.14%) 5,132 Skilled Nursing 8,840 (98.12%) 9 (0.10%) 160 (1.78%) 9,009 GRAND TOTALS 17,070 (96.73%) 52 (.29%) 525 (2.98%) 17,647
CHNCT Intensive Care Management Intensive Care Management is a member centered program developed to support our members in reaching their own health goals through education and access to quality healthcare.
ICM Program Design • Regionalized Care Teams • Comprehensive assessment of needs • Culturally sensitive • Hybrid Model - F2F visits when appropriate • Specialized Care Management
Regionalized Care Teams Multi-disciplinary Care Teams service 5 regions of Connecticut • Registered Nurse and Advanced Practice Registered Nurse • Medical Social Worker & Social Services Coordinator • Human Services Specialist • Registered Dietician • Certified Diabetic, Child Birth, and Wound Care Nurses • Care Coordinator • Pharmacist • Medical Director
Regionalized Care Team Functions Specialized teams to address the member’s unique needs: • Unstable conditions • Medical with behavioral health needs • Chronic diseases • Maternity, Newborn and Children with special healthcare needs • Medical with unmet social needs
Comprehensive Assessment • Adequate Food, Safety and Shelter • Identify Barriers to Care and Personal Strengths • Depression Screening • Stress Levels • Self Care Abilities (Functional) • Medication Understanding and Safety • Provider Access and Engagement • Condition Stability • Health Literacy • Self Care Understanding
Community Support Services Human Services Specialists • Comprehensive telephonic assessment for basic needs • F2F home visits with members • Social Service and Community Resource referrals • Assistance with completion of applications • Continued follow-up for 90 days • Ages and Stages Screenings
ICM Coaching and Education • Chronic Condition Coaching • Preventive Care Coaching • Knowing their targets, triggers and action plans • Knowing their numbers (Blood Pressure, Blood Glucose, Cholesterol, Weight, Peak Flows, etc.)
Asthma Example • Focuses on Medications, Home trigger assessment and Education • Asthma Action plan is provided • Brochures • Provide resources to eliminate asthma triggers • F2F visits are conducted
How Can We Help You? • Assist with finding HUSKY providers • Assist with obtaining DME • Address Pharmacy issues • Facilitate/Coordinate MD appointments • Appointment reminder calls • Assist with transportation coordination • F2F visits with you and members • Provide alternatives to unnecessary Emergency Room visits
Referral Process • Go to http://www.huskyhealth.com • Click on ‘For Providers’, Provider Bulletin & Forms and select ICM Referrals Form • Contact Provider Line 1.800.440.5071 x2024 to request ICM services • Fax ICM Referral Form to 1.866.361.7274
CHNCT Intensive Care Management Contacts Dawn Clavette, RN Manager Specialized Intensive Care Management 203.949.6089 email@example.com Margy Roberts Manager Community Support Services 203.626.7276 firstname.lastname@example.org Nancy Sienkowski, RN Manager Intensive Care Management 203.626.7274 email@example.com
Hospital Readmission and ED Reduction Program Goals CHNCT is collaborating with members and providers to: • Develop approaches to support members and providers in effective discharge planning • Improve member self-management skills to decrease exacerbation of chronic disease events • Promote a trusting and collaborative member/PCP relationship. • Educate members on access to appropriate and available resources of care when faced with health related situations
Why is the Hospital and ED Reduction Program Needed? Member’s with complex chronic medical conditions and/or psychosocial needs receive health and homecare services from numerous providers in several types of healthcare settings. Fragmented care often results in: • Duplication of services • Diminished quality of care • Avoidable hospital readmissions • Emergent care utilization When possible, members should be treated by their Primary Care Provider for non-emergent conditions in order to promote consistent, quality care.
CHNCT Resources CHNCT addresses ED utilization and readmissions with the following interventions: • ED and Inpatient Discharge Care Management (IDCM) • Primary Prevention (connecting to Primary Care Providers) • Information Sharing-Data Analytics • Claims Analysis (Pharmacy Medication Adherence) • Secondary and Tertiary Interventions • Hospital Discharge Collaborative Rounds • Intensive Care Management (ICM) post hospital discharge • 24/7 Nurse Advice Line • Enhanced access and continuity of care through collaboration with providers at Person-Centered Medical Homes and Federally Qualified Health Centers
How are these resources used? CHNCT resources aimed at hospital readmission and ED reduction are available to: • Facilitate communication among hospital care managers, attending physicians, primary care providers, specialists, health and community providers, patients, and caregivers • Assist in early identification in gaps and barriers to care • Address psychosocial issues • Facilitate a coordinated plan of care • Help patients identify and access resources within the community • Reduce avoidable hospitalizations and ED visits
How is this achieved? ED and IDCM Focus CHNCT places Inpatient Discharge Care Managers (IDCMs) on site at the hospital to collaborate with the patients, hospital care managers, social workers, primary care providers, and caregivers to: • Identify and address clinical and psychosocial gaps in care that contribute to readmission and ED recidivism • Facilitate communication among the member, caregivers, interdisciplinary medical and behavioral healthcare team, and other community providers • Engage members with CHNCT’s Intensive Care Management Program and Human Services Specialists • Assist in the development of a comprehensive discharge plan to ensure optimal and effective transition of care to the most appropriate setting
How is this achieved? (cont.) IDCM Collaboration Efforts For members with frequent ED visits for medical diagnoses (non-behavioral health) IDCMs collaborate with hospital Social Workers and Care Managers to: • Assess and determine underlying causes of frequent ED visits • Identify any resources the member is already receiving in the community and determine the member’s compliance and the resources’ effectiveness • Outreach to providers to coordinate changes to existing services that may be appropriate in order to address identified issues • Facilitate the member/PCP relationship • Educate the member on ED alternatives such as: • Same day visits • Urgent care • 24/7 Nurse Advice Line
How is this achieved? (cont.) IDCM Collaboration Efforts (cont.) For inpatient members with frequent readmissions, IDCMs collaborate with hospital Social Workers and Care Managers to: • Perform onsite assessment of admitted members to ensure that appropriate discharge plans are in place to allow the member’s care to continue in the appropriate alternate setting • Assess the member’s ability to self-manage care and identify gaps in current outpatient services and the treatment plan which may be contributing to the need for readmissions • Procure appropriate medical and psychiatric evaluations to determine member’s competency and ability to self-manage, where appropriate
How is this achieved? (cont.) IDCM Collaboration in Discharge Planning IDCMs assist in identifying and addressing barriers to safe discharge, including: • Needs for housing, foster care, or alternate living arrangements • Lack of compliance and/or poor therapeutic response to Home Services that are currently received • Inability to receive homecare or other medical services in the member’s current living environment • Inadequate level of oversight and/or clinical services available • Poor ability to access medical care in the community • IDCMs communicate barriers to safe discharge with the hospital care managers, attending physician, and PCP and assist in implementing a safe discharge plan of care • For members requiring assessment and assistance navigating the behavioral healthcare system, IDCMs will refer to Value Options
How is this achieved? (cont.) IDCM Collaboration with Other ASO Programs Elements of CHNCT’s Person-Centered Medical Home Program that directly impact readmission and ED rates include: • Availability of access during and after office hours (including weekends) • Coordination and continuity of care across all areas of healthcare • Primary care offices acting as the main portal for all member’s post-discharge follow-up needs • Providers educating members and caregivers on self-management strategies • Medication management and reconciliation • Open appointments dedicated to post-discharge follow up • Coordination of transportation to appointments
How is this achieved? (cont.) IDCM Collaboration with Other ASO Programs (cont.) • Member’s who require ongoing support post hospital discharge are referred to CHNCT’s Intensive Care Management Program (ICM) to address member’s specific issues related to their high ED utilization and readmissions. • Member’s who also face barriers related to immediate, unmet basic human needs are referred to Human Services Specialists, an extension of ICM, for assistance in navigating resources available within their community. • IDCMs will also refer members who have funding needs for services not covered under their benefit program to Waiver Programs and other community resources.
In Summary • CHNCT’s goal is to provide a complete and comprehensive plan for transition from inpatient to the community • CHNCT program goals are to facilitate communication among the hospital multidisciplinary team, primary care provider, specialists, members, their families and caregivers • Prevent avoidable readmissions, ensure provider follow-up and assist to address barriers to care • Engage members in Intensive Case Management and refer to Human Services Specialist or CTBHP, when appropriate
Personal Automated Medication Dispensers Coverage Guidelines and Prior Authorization Process
Personal Automated Medication Dispensers Clinically Appropriate for Individuals: • With mild cognitive impairment • With visual impairments • With previous hospitalizations or ED visits • Who have been unable to adhere to a medication regimen Contraindicated for Individuals: • With potential to hoard medications • With potential to sell medications
Prior Authorization Information Required for Review • Prior Authorization Form • Documentation of a Home Visit • Documentation from requesting Physician • Medical records as requested
Authorization Form • Request using code S5185: Medication reminder service, non-face-to-face; per month • S5185 covers both medication box rental and monitoring services • 1 unit = 1 month • A request for authorization of at least one skilled nursing visit should also be submitted on the prior authorization request
If PA Request for Automated Medication Box is Approved: • Initial authorization period is 30 days • The agency will provide and oversee the use of the dispenser • Skilled nursing visit(s) should occur during the first one to two weeks after the individual receives the device to ensure the proper use of the device as well as to reinforce medication education including self management skills • Subsequent requests must include clinical documentation that supports maintenance or improvement in compliance and may be approved for up to 6 months