Lifemark Long Term Care Experience

1. Lifemark Long Term Care Experience December 15, 1999

2. The Lifemark Mission • Through innovative care management services and technology offerings, Lifemark strives to create fundamental change in the well being of vulnerable, frail, elderly and chronically ill people.

3. Locations • Phoenix, AZ (Corporate Office) • Albuquerque, NM • Fort Smith, AR • Honolulu, HI • Houston, TX • Indianapolis, IN • Lansing, MI • San Diego, CA

4. LIFEMARK CORPORATION Care Management Strategies for “At Risk” Populations December 1999

5. Why is Long Term Care (LTC) a heightened issue? Complex Benefit Coordination Aging Population Prevalence of Chronic Conditions Longer Life Expectancies

6. LTC HCBS “Single Entity” Behavioral Health Medical Care Svcs The Coordinated Model Integrated Services • Long Term Care • Home and Community Based Services • Behavioral Health • Medical Care Services: • Inpatient/Outpatient care • Physician • Lab/Radiology • EPSDT • Transportation • Ancillary Services • Specialist • Pharmacy • DME • Therapies • Coordinated Medicare fee-for-service and/or Medicare HMO Benefits

7. Coordinated LTC Model Full Continuum of Placement Options Most Restrictive Least Restrictive Skilled Nursing Facility Specialty Unit within a nursing facility Adult Care Home Adult Foster Care Home Assisted Living/ Residential Care Home or Apartment

8. Patient Centered CareCase Manager’s Role • Nurses, Social Workers, or those with 2 years case management experience • Coordinator, facilitator, investigator, service broker, liaison, and advocate who is empowered to authorize and verify services • Leads team of decision makers Case Manager Patient PCP Family or Representative • Closely linked to PCP, patient and family

9. Care Management SystemsInitial In-Depth Assessment • Highly automated using laptop computers • Performed within five days of enrollment • Current/previous medical status • Socioeconomic profile • Psychological assessment • Functional assessment (ADLs) • Develop multiple alternative care plans for service(s), placement, provider, and/or reassessment schedule • Level of care determination • Perform cost effectiveness study • Initiate/authorize: • Formal service plan • Actual placement • Establish measurable goals Care One

10. Care Manager Scope of Authorization • LTC Services/Placements include • Nursing Facility • Assisted Living/Personal Care Home/Adult Foster Care • Adult Day Care • Community based alternatives • Medical Supplies/DME • Value Added Services • Home Services • Personal, Attendant, and Chore Services • Skilled Home Health Care/Short term therapy • Emergency Response Systems • Meals on Wheels • Respite

11. Patient-Centered CareCritical Elements to Success • Develop intense, fully integrated care management system to consolidate funding, limit fragmentation/duplication, monitor quality, outcomes, clinical utilization and costs • Establish an HCBS infrastructure and expand covered services to include full menu of HCBS services • Perform outcomes, placement and cost comparisons for effective service alternatives

12. Arizona/Texas LTC Program(s) • State Medicaid Agency Retains Responsibility For: • Determining Member Program Eligibility (Both Financial and Medical) • Health Plan Assignment • HCFA Waiver/State Regulations • Program Compliance Monitoring/Auditing • RFP Development, Scoring and Awards

13. Arizona Ventana Health SystemsA Wholly Owned Subsidiary of Lifemark Corporation • Arizona Health Care Cost Containment Systems’ Long Term Care System (ALTCS) program contractor since January 1989 • Serving the most chronically ill of the Aged, Blind and Disabled at-risk for nursing home placement • Providing services in 9 rural counties of Arizona • Pre-paid, capitated health plan for 1,900+ LTC members • A fully integrated services approach coordinating institutional, home and community based services, behavioral health, pharmacy and medical care services • Member satisfaction indicates improved functionality and quality of life

14. Impact on Member PlacementMovement Toward Home and Community Based Services Percentage of Lifemark/Ventana Health Plan Members in Institutional vs. HCBS Settings Source: Ventana Health Systems Claims and utilization data.

15. Arizona Ventana Health SystemsA Wholly Owned Subsidiary of Lifemark Corporation • Caseload limits are (case manager-to-member ratios): • 1/48 HCBS, acute care/hospice members (visits every 90 days) • 1/120 nursing facility members (visits every 180 days) • One case manager for mixed caseload of approximately 96 clients (nursing facility and HCBS) • Ventilator dependent members case managed based on setting • Subset of Clinical quality outcomes are monitored by measuring: • Influenza • Sacral/Coccygeal pressure ulcers • Hospitalization and emergency room utilization • Activities of Daily Living • Fractures related to falls

16. Texas HMO BLUE/STAR+PLUS100% AdministeredManaged by Lifemark Corporation • Pilot demonstration started in Harris County (Houston), Texas January 1998 • Integrates acute medical, LTC, behavioral and community based services into a managed care delivery system • Emphasis on least restrictive setting and intensive care coordination • Three health plans awarded contracts, covering over 52,000 members • Primarily mandatory enrollment • Lifemark manages over 19,700 LTC (NF and CBA) and SSI (ABD) recipients - the largest in the STAR+PLUS program

17. Texas HMO BLUE/STAR+PLUSManaged by Lifemark Corporation • Caseload limits are determined by need (case manager/member ratios): • Level I - 1/2,500 members • Level II - 1/250 members • Level III - 1/100 members • Level IV - 1/30-60 members • Current clinical quality outcome studies are: • Depression • Childhood asthma • Adult diabetes • Breast cancer screening