Managed Care and Homeless Populations: Linking the HCH Community and MCO Partners

1. Managed Care and Homeless Populations: Linking the HCH Community and MCO Partners • April 5, 2016

2. Welcome • Learning Objectives: • Understand the factors influencing Medicaid managed care plans and their approach to serving people experiencing homelessness and how they are seeking opportunities to partner with providers serving the population • Understand how the HCH Community can maximize common goals with managed care plans • Describe how two Health Care for the Homeless projects in Washington State (one urban and one rural) are partnering with a managed care plan for medical respite services. • Speakers: • Catherine Anderson, Vice President, Positioning and Strategy, UnitedHealthcare Community & State • Barbara DiPietro, Senior Director of Policy, National HCH Council • Doug Bowes, CEO, UnitedHealthcare Community Plan of Washington • Edward Dwyer-O'Connor, BS, RN, Senior Manager, Downtown Programs, Harborview Medical Center, Seattle, WA • Matt Lund, Director of Contracting, UW Medicine at Harborview Medical Center, Seattle, WA • Rhonda Hauff, COO/Deputy CEO, Yakima Neighborhood Health, Yakima, WA

3. Background on Initiative • Recognized Interest • 2015 Healthcare for the Homeless Annual Conference • Began conversations • Co-wrote the white paper and developed today’s webinar • Beginning to an on-going conversation

4. National Context • Medicaid Expansion • Growing Footprint of Medicaid Managed Care • Greater Recognition of Social Determinants of Health Source: HMA Value of Medicaid Managed Care

5. Medicaid Managed Care Source: Architect of the Capitol • Health Plans • Administer the Medicaid program according to the terms of the contract with the state for their assigned Medicaid beneficiaries • Measured on ability to support their members in receiving preventive treatment, achieving state goals, and meeting other quality metrics established by the state • Established contracts with providers • State Governments • Establish program rules, benefits, eligibility, contract provisions and the rates health plans will be paid to administer the Medicaid program • Compensates the health plans using a per member per month capitated rate • Federal Government • Establishes basic rules and criteria States must follow in the design and operation of a Medicaid program • Covers a significant portion of the costs of Medicaid (varies by state and population) • Approves contracts and rates between states and managed care entities Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

6. Care Models Evolve Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

7. Policy Considerations • Medicaid benefit and program design matters! • Expansion vs. non-expansion • Populations under managed care contract • Benefits under managed care contract – behavioral health, LTSS/HCBS, housing supports, etc. • Medical Loss Ratio calculations • Care coordination requirements • State program priorities • Delivery and payment reform requirements • Quality definitions, calculations and accountability Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

8. Needed for Success • Countless opportunities to collaborate exist, but resources and capacity on both sides are limited • Evaluating opportunities: • Members impacted • Opportunity to improve quality • Opportunity to improve utilization • Data available to support the decision to invest, track and demonstrate impact • Presence of trusted partners willing to innovate with unique skills and expertise Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

9. Washington Panel on MCO & HCH Collaborations

10. Washington Panel Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Doug Bowes, CEO, UnitedHealthcare Community Plan of Washington • Edward Dwyer-O'Connor, BS, RN, Senior Manager, Downtown Programs, Harborview Medical Center, Seattle, WA • Matt Lund, Director of Contracting, UW Medicine at Harborview Medical Center, Seattle, WA • Rhonda Hauff, COO/Deputy CEO, Yakima Neighborhood Health, Yakima, WA

11. Medical Respite Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Medical respite care is acute and post-acute medical care for homeless persons who are too ill or frail to recover from a physical illness or injury on the streets but are not ill enough to be in a hospital. • Unlike “respite” for caregivers, “medical respite” is short-term residential care that allows homeless individuals the opportunity to rest in a safe environment while accessing medical care and other supportive services. • Medical respite care is offered in a variety of settings including freestanding facilities, homeless shelters, nursing homes, and transitional housing.

12. Washington Context • Medicaid Expansion • Movement toward integrated physical and behavioral health • State Innovation Model Grant • Accountable Communities of Health • 1115 waiver with significant delivery system reforms Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • UnitedHealthcare Community Plan is the third largest Medicaid managed care plan in Washington State providing physical health benefits and services to more than 210,000 members • We provide face-to-face and telephonic care coordination services for our most complex members, including many that are homeless • Washington Medicaid program has continually sought significant reforms and modernization including:

13. Health Plan Journey Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • Recognized need • Built off Established Relationships • Learned about Jefferson Terrace Program • Made the case internally • Worked out the details and executed contract • Replicated with Yakima Neighborhood Health Services • Continuing to look for ways to improve coordination, care transition and evaluation

14. Value of Collaboration Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. • We were interested in seeing to it that our members were able to access the care and recovery environment they needed and to keep them from facing recovery and recuperation on the streets or in a shelter. • Reducing hospital readmissions • Improving the health of the member • Partnering with medical respite helps to create an essential care linkage opening the door to additional physical and behavioral health care coordination and holistic social support services, all of which uphold our driving goal of the Triple Aim.

15. Edward Thomas House • Respite history in Seattle • Free-standing unit in Jefferson Terrace/SHA/HUD • Harm Reduction Program/34 beds • Designed for high medical and behavioral acuity • Braided funding; money from 6 hospitals, Public Health – HUD, HRSA, local MIDD funding and MCOs. • Hospitals needed IV antibiotic treatment for IVDU • 475 patients/year. LOS 21 days. Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

16. WHO DOES RESPITE SERVE? • Homeless men and women with complex needs [too sick for the streets, not sick enough for the hospital] • Acute medical issues; often abscesses and infections R/T IVDU • IV antibiotics often 4-6 weeks • Multiple chronic conditions • Preponderance of chemical dependency plus mental illness • Patients must be independent in mobility [wheelchair OK] • Behavior must be safe for the setting [no threats, violence, weapons] • Cannot use drugs on the unit • Able to serve much higher acuity [staff includes MD, ARNPs, RNs, MHPs, MHSs, Mas, custodial and data manager] • Goals for care include; access to entitlements, primary care, case management services, housing, opiate replacement therapy, chemical dependency treatment • Client story

17. APPROACH • Risk sharing and collaboration • Search for innovative ways to provide care for underserved, high cost patients • Manage the whole person • Look for leverage points in the Triple Aim • Reduce costa • Improve outcomes • Find data to support outcomes and decreased costs [EDH study of 69 patientsshowed 70% reduction in hospital days 6 months post respite compared to 6 months pre-respite, a 57% reduction in inpatient admissions also decrease ED visits by 10%] • MCOs could not pay for respite stay, needed Health Care Authority to allow payment

18. Path to a Contract • Gained authorization from state Medicaid agency to bill/reimburse for respite care • Directed to bill and reimburse under G9006 “Coordinated Care Fee, Home Monitoring” • Determined how and how much to charge • Consulted revenue cycle, contracting, utilization management, and social work departments to ensure full understanding of work flows • Assembled helpful data and analysis demonstrating efficacy and cost effectiveness of program • Hosted tours of facility for managed Medicaid plan reps • Approached managed Medicaid plans with pitch to contract for respite services

19. Contract • Coverage and reimbursement established through amendment to existing agreements • Discussed possible models for reimbursement (per diem, case rate, etc.) • Discussed: concurrent review/UM needs, program definitions, scope of services, other expectations • Negotiated key terms, executed amendments, and monitored events (care delivered, charges issued, reimbursements paid, problems solved, lessons learned) • Agreement to meet and discuss specs, successes/challenges, and needs on a regular basis • Recognition of cost savings and improvement of individual and population health

20. YNHS Mission To provide accessible, affordable, quality health care, promote learning opportunities for students of health professions, endhomelessness and improve quality of life in our communities.

21. Satellites Serve Special Populations Homeless Respite - Recuperative Housing for those not sick enough to be in the hospital, and those discharged from the hospital but not well enough to go back to the streets

22. Homeless Respite Patients Since the ACA

23. Respite Activities Hospital Same Day Surgery Center • Respite Staffing: • Registered Nurse • Behavioral Health Specialist • Outreach Worker • Care Coordinator / Case Manager • Housing Specialist • Backed by CHC providers, nutritionists, dentists, pharmacy PCP • Intake: • Discharge summary • Medication list and reconciliation • Follow up instructions, appointments • Pending procedures • Pain management plan • Determine functional status, communication needs

24. Average Respite Stay in 2015 = 21 days Daily checks by Nurse / Behavioral Health / Case Manager. Wound care. Behavioral Health counseling. Transport / accompany to PCP and specialty and OT/PT appointments. Evaluate and support ADLs. Assist with applications for SSI/SSDI, Basic Food and other federal/state benefits. Facilitate family interaction when possible. Initiate housing stabilization. Provide discharge summary to patient /PCP at time of respite exit.

25. Help is On the Way… SIESTAS • Who do we SIESTA: • Chronic medical or social needs • Cause upheaval in the social service system • Seen by multiple service providers • Use a LOT of resources - repeatedly ServingIndividuals toEndSeriousTrouble throughAgencies’Support

26. 2015 – 47 patients stayed 1,011 Days- Here’s Why Outcomes

27. Respite care reduces public costs associated with frequent hospital utilization. Hospital Staff report a Savings of 23 Inpatient Days by referring to YNHS Medical Respite Care$28,543 Saved for Inpatient Depression, or $82,800 for Inpatient Rehab! Outcomes *WSHA Hospital Pricing - does not include professional fees in charges

28. Outcomes 43 People Exited Respite in 2015 Yakima has less than a 1% rental vacancy rate. We need more Affordable Housing, and more Permanent Supportive Housing to keep our patients healthy. • 6 patients exited to the hospital, transitioned by PCP/respite team • 2 new admits • 4 re-admits

29. “I am not a Homeless Guy Any More…”

30. Health Home Services YNHS works with 3 MCOs providing Health Home Services Targets high cost Medicaid and Dual Eligible clients. Provides intense care coordination and support for high needs patients. Sounds like our homeless population! HCH staff certified as Health Home Care Coordinators Last year YNHS staff provided Health Home Care Coordination to 230 unduplicated patients through our CHC – 55 (23%) were homeless.

31. Discussion/Q&A • Speakers: • Catherine Anderson, Vice President, Positioning and Strategy, UnitedHealthcare Community & State • Barbara DiPietro, Senior Director of Policy, National HCH Council • Doug Bowes, CEO, UnitedHealthcare Community Plan of Washington • Edward Dwyer-O'Connor, BS, RN, Senior Manager, Downtown Programs, Harborview Medical Center, Seattle, WA • Matt Lund, Director of Contracting, UW Medicine at Harborview Medical Center, Seattle, WA • Rhonda Hauff, COO/Deputy CEO, Yakima Neighborhood Health, Yakima, WA

32. Additional Resources • Policy Brief: • Managed Care & Homeless Populations: Linking the HCH Community and MCO Partners • Available at: • https://www.nhchc.org/wp-content/uploads/2016/03/mco-hch-policy-brief.pdf • Medical Respite Tool Kit: • Intro & overview • Development & finance • Collaborating with hospitals • Operations & clinical care • Available at: https://www.nhchc.org/resources/clinical/medical-respite/tool-kit/ Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

33. Thank you • Thank you for attending this webinar on Managed Care and Homeless Populations: Linking the HCH Community and MCO Partners! • This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U30CS09746, a National Training and Technical Assistance Cooperative Agreement for $1,625,741, with 0% match from nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government. Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.