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Managing Care in Wisconsin

Managing Care in Wisconsin. Donna McDowell, MSS, Director Bureau of Aging & Disability Resources Division of Long-Term Care Dept. of Health Services NASHP October 4, 2011. Publicly-Funded Long-Term Care Clients by Setting. 66%. 61%. 39%. 34%. How Does Change Happen?.

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Managing Care in Wisconsin

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  1. Managing Care in Wisconsin Donna McDowell, MSS, Director Bureau of Aging & Disability Resources Division of Long-Term Care Dept. of Health Services NASHP October 4, 2011

  2. Publicly-Funded Long-Term Care Clients by Setting 66% 61% 39% 34% D. McDowell - Wisconsin

  3. How Does Change Happen? • People want something better • Choice matters • Access to an array of opportunities • Quality is very personal • Cost-effectiveness is essential • Combine available resources • Create good business models D. McDowell - Wisconsin

  4. Look Familiar? D. McDowell - Wisconsin

  5. END WAITING LISTS “There’s No Place Like Home!”

  6. Medicaid LTC Funding • Waivers – residential, vocational • Nursing Home • Home health, DME, DMS, therapies • State-only Community Options D. McDowell - Wisconsin

  7. Coordinate v. Integrate • Hospital • Physician • Acute • Primary • Rx • Hospice D. McDowell - Wisconsin

  8. Medicaid Managed Care Program for SSI and SSI Related Recipients • 2003-05 Biennial Budget required certain SSI recipients to enroll in MA managed care • Individuals dually eligible for both Medicare and Medicaid may enroll voluntarily. • All eligible individuals, aged 19 and older who are SSI MA not currently enrolled in a managed care program (Family Care, PACE, or Partnership), are enrolled. Choice, after an initial two month mandatory trial period, to opt out of the program. • Fifth month enrollees are locked into the managed care plan for an additional eight months. D. McDowell - Wisconsin

  9. Aging & Disability Resource Centers • One-stop shopping for information and advice about issues of age, disability and long-term care. • Easy access to knowledgeable professionals about programs, housing and eligibility. • Counseling about array of options for private pay and indigent clients D. McDowell - Wisconsin

  10. Objective and Prompt Service • Uniform questionnaire screens individuals to determine what difficulties person has functioning (functional screen). • Web-based functional screen automatically determines eligibility for public programs: Family Care, Partnership, IRIS • Easy access to prompt financial eligibility determination D. McDowell - Wisconsin

  11. Combining Services Under One Umbrella • Elderly benefit specialist • New disability benefit specialist • Prevention of disability, e.g. elderly falls prevention • Transitions for children with disabilities to adult programs • Information and assistance for persons with mental health concerns D. McDowell - Wisconsin

  12. Enrollment Counseling • Mandatory for managed care • Organizationally independent of MCO • Public entity • Functional eligibility (home visits) • Explain program elements • Support decision-making • Enroll individual in program of their choice D. McDowell - Wisconsin

  13. Expansion • Current 35 ADRCs for 55 counties • Serve 85% of population • Statewide expansion by 2013 • $50 million AF; claim MA thru time reporting • 350,000 contacts/year • Tribal Aging & Disability Specialist • Milwaukee ARC & DRC D. McDowell - Wisconsin

  14. OPTION: Family Care • Elderly, physically or intellectually disabled • Over 40% have mental health problems • Integrated, person-centered LTC • Social Worker/Nurse Care Team • Comprehensive Assessment • Care Plan identifies personal goals • 8 MCOs:non-profit, county,public authority • Provider network to met all needs D. McDowell - Wisconsin

  15. Family Care Costs • 31,256 members in 2010; av. $2900 pmpm • $976 million Family Care: adaptive ,DME,day, care mgt, home care, home health, therapies, housing, residential (no room/ board), respite, transport, vocational, nursing home • $94.8 million Medicaid: acute, primary, hospital, doctor, Rx fee-for-service not in cap rate • Approaches to incentivize care at home are key to cost-effectiveness & sustainability D. McDowell - Wisconsin

  16. OPTION: Partnership • Integrates Long-Term and Primary Care • Integrates Medicare and Medicaid • Nurse Practitioner & Social Worker team • Special needs plan • 3 non-profit MCOs in 8 counties (incl. Milwaukee) also provide Family Care • For-profit (also SSI managed care) • One PACE: two sites D. McDowell - Wisconsin

  17. Self-Direction • IRIS – Include Respect, I Self-direct waiver services • 3393 IRIS participants • Family Care has 3,000 members self-directing services of their choice • IRIS waiver does not include MA ffs; participants can self-direct MA personal care D. McDowell - Wisconsin

  18. Information on Website • Family Carehttp://dhs.wisconsin.gov/ltcare/ • Family Care Partnershiphttp://dhs.wisconsin.gov/wipartnership/ • ADRChttp://dhs.wisconsin.gov/ltcare/adrc • Family Care Expansion http://dhs.wisconsin.gov/managedltc/ • Medicaid SSI HMO Choice Booklet http://www.dhs.wisconsin.gov/publications/p1/p12770a.pdf • ForwardHealth Enrollment and Benefits handbook http://www.dhs.wisconsin.gov/em/impubs/pubs/p-00079.pdf D. McDowell - Wisconsin

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