San Diego Long Term Care Integration Project

1. San Diego Long Term Care Integration Project April 14, 2004 LTCIP Planning Committee Meeting

2. Announcements • Aging Summit: April 19, 2004, 7:30-3:30, San Diego Concourse • Next Planning Committee Meeting: May 4, 2004, 10:30-noon, County of SD, 8965 Balboa Ave, Conference room (1st floor) • Community Education Kick-off • Chair: Betty London

3. Community Planning Process • From 50 to 600+ key stakeholders over past 5 years: 12,000+ hours • Seeking to improve system of care for consumers and providers • Planning within state LTCIP authorization (form follows funding)

4. Long Term Care Integration Project Organizational Chart & Decision Tree San Diego County Board of Supervisors & State Office of Long Term Care Jean Shepard,Acting Director County of San Diego, Health & Human Services Agency, (HHSA) • Internet • Facilitates communication • Provides broad public education Pamela B. Smith, Project Director Evalyn Greb, Project Manager Aging & Independence Services Lead County Agency Advisory Group: Goal: Make final decisions and recommendations for inclusion in the plan. Planning Committee: Goal: Guide the LTCIP planning process. Suspended Workgroups pending service delivery model decision Health Plan Partners Workgroup Finance/Data Workgroup Options Workgroup MH & SA Workgroup Community Education Workgroup Incremental LTCI Strategies: 1) Network of Care 2) Physician Strategy 3) Health Plan Pilots Explore use of public health education models that promote improved chronic care management for LTCIP Determine the financial feasibility of the proposed LTCIP for San Diego County. Make recommendation to Planning Committee re: inclusion of mental health and substance abuse services in LTCIP. Explore use of the Healthy San Diego model for potential Service delivery system for LTCIP. Governance -Case Management -Info/Technology -Quality Assurance -Scope of Services -Workforce Issues -Community Network Development -Developmental Disabilities April 2004 www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/

5. San Diego Stakeholder LTCIP Vision for Elderly & Disabled • Develop “system” that: • Provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus • Pools associated (categorical) funding • Is consumer driven and responsive • Expands access to/options for care • Utilizes existing providers

6. Stakeholder Vision (continued) • Fairly compensates all providers w/rate structure developed locally • Engages MD as pivotal team member • Decreases fragmentation/duplication w/single point of entry, single plan of care • Improves quality & is budget neutral • Implements Olmstead Decision locally • Maximizes federal and state funding

7. Mrs. C • 84 year old woman lives alone • CHF, HTN, diabetes, hearing and vision loss, IADL dependencies • 16 medications by 6 MDs • Medicare and Medi-Cal beneficiary • Only child lives in Chicago

9. In-HomeServices PrimaryCare AcuteHospital MealsService MRS. C. DayHealthCare Transit Medical Specialty SkilledNursingFacility Ideal System Mrs. C & Care Manager Journal of the American Geriatrics Society, Feb. 1997

10. From Vision to Service Delivery Model… • Explore Healthy San Diego due to: • Access, education, prevention • Advocacy • Cost-effectiveness • Population-based • Existing infrastructure • Stakeholder-designed, BUT

11. HSD Expansion Areas… • Tailor the program for chronic care of aged and disabled persons • Provide “wraparound” services • Provide chronic care management on a population basis • Receive adequate reimbursement via Medi-Cal or Medi-Medi dual cap

12. Where are we now? • May ’02, BOS: “give us 3 options” • Since then: Dr. Mark Meiners assists w/strategies development: • Network of Care • Physician Strategy • HSD Health Plan/Pilot Projects

13. Network of Care • Beta testing with • consumers and caregivers • community based organizations • other providers, Call Center staff • Develop “continuous quality improvement” • Support 2 service delivery models • Measure behavior changes of providers and consumers • Assess potential as HSD+ info and communication database

14. Physician Strategy • Partner w/physicians vested in chronic care • Develop interest/incentive for support of “after office” services (HCBC) • Identify care management resources to support physicians/office staff to link patients and communicate across systems • Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports

15. Physician Strategy (cont.) • The California Endowment has provided resources for planning • Focus groups planned w/MDs, other providers, and consumers • Implementation Plan for review by 6-05 • PS implementation 7-06 with HSD+ • Current HeartPartners opportunity

16. Health Plan Pilots • Pilots to do small, voluntary models of care integrated across the health, social, and supportive services continuum: • Private entity to contract with State through RFP with stakeholder support (AB 2822) • Healthy San Diego Health Plans to develop phase-in with rate cells adjusted for function and setting = HSD+

17. Consultant Team for AAP • Dr. Mark Meiners, National Program Director, RWJ Medicare/Medicaid Integration Program • Mercer Government Human Services Consulting • LTCIP Staff and Stakeholders

18. Administrative Action Plan for Healthy San Diego Plus (HSD+) • “Vision” for chronic care system • Governance and administration • Population, services, delivery system • Care management and integration • Financing and cost neutrality • Quality management & improvement • Integrated information system • Phase-in strategy

19. AAP Highlights • Begin voluntary enrollment July ‘06 for 300 elderly per month, Medi-Cal or Medi-Medi • Use rate cells adjusted for care setting and functional level • DHS & CMS contract with extensive provider networks (health & social services) • Care manager & enrollee at “hub” • Quality control mechanisms required

20. Overview: Milestones and Target Dates • Draft AAP discussion w/ LTCIP PC (today) • Update County BOS (5/04) • Revise AAP; Gain consensus (4/04-6/04) • Submit County-approved AAP to DHS OLTC (6/30/04) • Present concept paper to CMS (9/04) • Waiver approved(s) (7/05) • State contract awards determined (2/06) • Pre-enrollment activities (3/06-5/06) • Begin Phase I implementation (7/06)

21. Governance and Administration • Expand HSD Infrastructure: Operating Agency and Governing Body • Pre-qualify Provider Networks through RFSQ process • 3-way contract: DHS/CMS/Provider Network • Medicare/Medi-Cal caps pooled at plan level • System mgmt – County BOS, HHSA Director • Service mgmt – contracting provider network

22. HSD Joint Consumer & Professional Advisory Committee HSD Program Manager County of San Diego, HHSADirector Policy & Program Support Division Deputy Director Medical Care Program Administration Senior Program Manager HSD+ Program Manager Analysts III Analysts II Sup Com Hlth Prom Specialists Sup Com Hlth Prom Specialists HSD+ Organization Chart

23. Governance & Administration: Milestones and Target Dates • Expand membership of Joint Committee (1/05-1/06) • Present/discuss draft of RFSQ (6/05) • Finalize and release RFSQ (9/05) • Complete RFSQ evaluations and forward to State (1/06) • Perform readiness review of contractors (2/06-4/06) • Train additional HSD+ staff; make other systems modifications (1/06-12/06)

24. Population, Scope of Services, Delivery System • Begin with elderly (65+); phase in younger disabled at later date • All Medicare & Medi-Cal state plan services(State plan services for Medi-Cal only). Plus value-added home and community-based services. • Provider networks responsible for network development & coordination • MOU’s for frequently used off-plan services • Consumer Interface/ Cultural Competence • Demonstration of stakeholder support

25. Population, Services, Delivery System: Major Milestones and Target Dates • Complete Population and Scope of Services forms (10/04) • Establish budget neutrality criteria (12/04) • Establish provider network requirements (4/05) • Develop policy regarding off-plan service coordination (6/05) • Finalize call center consumer interface protocols (1/06-4/06) • Define “complex care needs” (6/05) • Update/expand MOU’s (1/06-6/06)

26. Care Management & Integration • Care manager & enrollee at “hub” of system • Provider Networks sub-contract for care mgmt w/ AIS and/or CBO • Care mgmt standards will be specified in RFSQ • “No wrong door” entry to AIS Call Center for eligibility & options counseling • Standardized assessment by contractor to determine level of care • Contractor/Consumers engaged in chronic care self-management (Com. Ed Workgroup)

27. Care Management & Integration: Milestones and Target Dates • Define minimum care mgmt & integration standards for RFSQ (1/05) • Define minimum contents of Integrated Care Plan (3/05) • Determine standards for Contractor evaluations of care manager (5/05) • Define contents and accessibility of care mgmt database (5/05) • Develop web-based data system to support chronic disease self-management (5/06)

28. Financing and Cost Neutrality • Dual funding from Medi-Cal and Medicare will allow a single contractor to provide the most appropriate and cost-effective combination of services for individuals • Multiple Medi-Cal capitation cohorts (to match reimbursement to risk) • During first phases of implementation offer risk sharing and/or stop-loss mechanisms to contractors • Medicare capitation structure still to be negotiated • Rates that are developed must be budget neutral to be approved

29. Financing and Cost Neutrality: Milestones and Target Dates • Contract/plan in place for actuarial support (9/04) • Review detailed reimbursement approach with LTCIP Planning Committee and potential contractors (12/04) • Perform cost analysis for budget neutrality (1/05) • Perform gap analysis of system(s) requirements related to reimbursement approach (2/05) • Obtain State approval of reimbursement approach (3/05) • Begin capitation rate development process (4/05) • Final capitation rates developed (12/05)

30. Quality Management & Improvement • Contractors will be required to demonstrate utilization review and management processes • Contractors will have primary responsibility for resolving complaints and appeals (grievances), however other levels of review will exist • RFSQ will specify reporting related to quality – focus on outcomes and performance improvement • RFSQ will specify quality improvement initiatives • External surveys and reporting will be performed such as EQRO, HEDIS, and CAHPS

31. Quality Management & Improvement: Milestones and Target Dates • Define the complaint and appeals protocol (1/05) • Define County’s method/process to monitor quality management requirements (2/05) • Develop policies and standards of utilization review and management for RFSQ (3/05) • Define required QM reporting for RFSQ (4/05) • Determine Contractor standards for provider credentialing and provider profiling • Draft materials to be provided in writing to consumers about the complaint and appeals process (1/06)

32. Integrated Information System • Web-based system that supports the integration of care across the continuum of providers of health, social, and supportive services • Contractors will be required to collect and retrieve data on an individual patient basis and in the aggregate • Pre-implementation planning will examine the Network of Care component as a potential vehicle to be the over-arching information and communication system • Two data support programs will be expanded for the aged and disabled population – Panorama View and GeoAccess

33. Integrated Information System: Milestones and Target Dates • Perform a gap analysis of system requirements against current system capabilities (2/05) • Plan with stakeholder to expand Panorama View and GeoAccess capabilities (3/05-5/05) • Define contents and accessibility of case management database (5/05) • Systems modifications and/or development (1/06-12/06) • Develop web-based data system to support chronic disease self-management (5/06)

34. Phase-in Strategy • Begin with voluntary enrollment of age 65+ to allow time for contractors to build expertise, an adequate network of providers, and infrastructure • Determine evaluation criteria with baseline data and benchmarks to measure the success of phases and to be able to justify moving to the next phase • Goals and performance criteria for each phase will be established and continuously modified with implementation • Implementation of program will be completed in no more than four phases (maybe fewer)

35. Phase-in Strategy: Milestones and Target Dates • Define evaluation plan criteria for baseline data and benchmarks for Phase I (1/06-5/06) • Enrollment of members with contractors (5/06-6/06) • Phase I implementation begins for 65+ in greater metro San Diego (7/06) • Phase II implementation begins, 65+ in entire County (7/08) • Phase III implementation begins, ages 21+ in entire County (7/10) • Phase IV, mandatory enrollment begins (7/12)

36. Questions & Comments