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Care/Service Coordination for Dual Eligibles Under the Financial Alignment Demonstration Virginia Department of Medical Assistance Services July 27, 2012 Karen Kimsey, Policy & Research Division Director Paula Margolis, Policy & Research Manager
Snapshot of Virginia’s Proposed Demonstration Population(Top 5 primary diagnoses, by setting, SFY 2012) • Inpatient Hospital • Chronic kidney disease • Diabetes • Cancer • SMI (includes depression) • Cerebrovascular disease (includes stroke) • Nursing Facility • Cerebrovascular disease • Dementia (includes Alzheimer’s) • Diabetes • Congestive heart failure • COPD • Physician • SMI • Diabetes • Mental retardation • COPD • Cancer
Care/Service Coordination & Care Management Care/Service Coordination – non-clinical functions such as: • providing information and logistical help to referred individuals, • assuring timely and effective transfer of patient information, • tracking referrals and transitions to identify and remedy glitches. Care Management - the more intensive care provided by nurses or other health workers to high-risk patients: • Encompasses both referrals and transition management, • clinical services such as monitoring, self-management support, • medication review and adjustment.
Service Coordination Value Proposition Reduce ED Use Risk Adjusted PMPM Premium High Quality Care High Quality of Life $$ Savings Redesign Primary Care -24 hour access -Ongoing relationship with PCP Reduce Hospitalizations; readmissions -Proactive/Preventive Home Care -Transition Assistance -End of Life Planning MCO Invest in Service Coordination/ Management Reduce SNF/LTC Admissions -Family &Caregiver Engagement -Home visits -Community LTSS & Back-Up Plans
Model of Care Requirements • CMS is requiring that health plans develop a Model of Care (MOC) that incorporates both CMS and State requirements. • Consists of eleven (11) clinical and non-clinical elements • States have the option to require one additional element beyond the required 11 elements to address certain topics or State-specific requirements. • CMS will review and approve MOC submissions based on their established scoring standards developed by NCQA. • CMS will coordinate review of the MOC with the State, and both the State and CMS will need to approve the MOC prior to the target date for joint plan selection.
MOC Elements & Standards • Describe population - Aged, Disabled, SPMI, etc. 2. Measurable Goals • Improve access to essential services, • Improve service coordination through identified point of contact, • Improve seamless transitions, • Improve access to preventive services, • Improve health outcomes. 3. Staff Structure & Care Management Roles • Identify employed and contracted staff to perform administrative and clinical functions and oversight. 4. Interdisciplinary Care Team • How the organization will determine the composition of the ICT; • How the beneficiary will participate in the ICT as feasible; • How the ICT will operate and communicate; and • How the activities of the ICT will be documented and maintained.
MOC Elements & Standards 5. Provider Network has Specialized Expertise & Use of Clinical Practice Guidelines and Protocols • Provider network expertise that corresponds to population, • Describe how network providers are licensed and competent, • Describe how providers coordinate with Interdisciplinary Care Team (ICT), • Describe how MCO assures use of evidence based guidelines. 6. Model of Care training for personnel and provider network • Describe how training is provided, materials used, method used, who is responsible for training, actions if training not completed. 7. Health Risk Assessments • Describe tool to ID specialized needs, • When and how completed, • Who reviews, analyzes, stratify needs, • Communication to providers 8. Individualized Care Plan • Who develops and how individual is involved (person-centered), • Essential elements in plan (goals, specific services, outcome measures, preferences, etc.), • Who reviews and updates plans, • How plan is documented, • How revisions communicated to individual, ICT, providers, etc.
MOC Elements & Standards 9. Communication Network: • Describe structure, e.g., web-based, face-to-face, audio conference, • How network connects the plan, providers, individuals, public and regulatory agencies, • How communications are documented, • Personnel having oversight of communication network. 10. Care management for vulnerable subpopulations • Describe how ID vulnerable subpopulations, • Add-on benefits/services for subpopulations. 11. Performance and Health Outcome Measurement • How and who will collect, analyze, report and act on measures, • How MCO will use results, • Who responsible for oversight/monitor effectiveness.
Minimum Expectations RegardingCare/Service Coordination • Individuals will be stratified into at least two levels of care/service coordination (basic and enhanced), based on needs. • Basic care/service coordination will include: • Single point of contact for all questions; • Assurance that referrals result in timely appointments and do not result in duplication or provision of inappropriate services; • Linkages to community-based services as necessary, including Aging and Disability Resource Centers and No Wrong Door; • Communication and education regarding available services and resources; • Assistance developing self-management skills to effectively access and use services.
Minimum Expectations RegardingCare/Service Coordination Enhanced care/service coordination will include: • Plan and coordinate with hospital and nursing facility staff for timely and appropriate discharges to the most integrated settings, • timely community-based and primary care follow-up post-discharge to prevent re-admissions; • For EDCD waiver participants - level of care re-evaluations and service plan updates to ensure necessity of waiver services and to identify unmet medical/social needs; • Arrange services that promote community living and help avoid premature or unnecessary nursing facility placements; • Nursing facility care coordination to prevent avoidable emergency department visits and hospitalizations and prevent or delay deterioration in functional status.
Minimum Expectations RegardingCare/Service Coordination • Enhanced care/service coordination will include: • Point person for individuals and caregivers to assist in obtaining services, answering questions, and sharing information, etc; • Maintaining and monitoring individual service plans; • Ensuring that individuals receive needed medical and behavioral health services, medications, LTSS, social services and supplemental benefits; • Setting up appointments and transportation; • Improving and maintaining functional health status; • Enhancing coordination and transitions across specialties and settings; • Reducing avoidable medical complications, emergency department use and hospitalizations; • Coordination with social service agencies; • Monitoring provided services.
Transitions • Requirements for transitions between levels of care and settings. • Acute care settings: • Discharge planning to ensure individual, families and environment prepared for return to home, • Evaluate for functional status changes, • Timely outpatient services follow-up, • Ensure medication reconciliation. • Community, including homes: • Home visits to ensure environment, LTSS and social needs met to support community living. • Institutional settings: • Ensure adequate primary, specialty and BH service, • Fall & pressure ulcer prevention.
Community Resources that Provide Care/Service Coordination & Care Management • Agencies/organizations that provide services, including existing partnerships; • Types of individuals served; • Values/services bring to the table; • Electronic communication systems/data support; • Considerations as DMAS moves forward.
Health Plan Experience • Expertise in providing care/service coordination and care management; • Types of individuals served; • Creative strategies implemented in other states ; • Electronic communication systems/data support; • Considerations as DMAS moves forward.
Next Steps • Meeting summary will be prepared and disseminated for review and comment • Model of Care Cross-walk • Quality measures • Future meetings as needed Remember to visit http://www.dmas.virginia.gov/Content_pgs/altc-enrl.aspx for information and updates on the Demonstration; Submit comments to: Dualintegration@dmas.virginia.gov.