Tackling Issues for Medicaid High-Utilizers

1. Tackling Issues for Medicaid High-Utilizers Essential Hospitals Engagement Network October 22, 2013

2. Our new Name We’ve rebranded! The National Association of Public Hospitals and Health Systems is now America’s Essential Hospitals. Although we’ve changed our name, our mission is the same: to champion hospitals and health systems that provide the highest quality of service to all by achieving the best health outcomes for every patient, especially those in greatest need. The new name underscores our members’ continuing public commitment and the essential nature of our work to care for the most vulnerable and provide vital community services, such as trauma care and disaster response. This is an exciting time for us and our members, as we lean forward into new care models, opportunities and challenges of reform, and quality and safety innovations that often take root in our member systems. Our new website address: www.EssentialHospitals.org

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5. Agenda • Introduction – Vickie Sears, RN, MS • Medicaid High Utilizers in the ED / San Francisco Health Plan CareSupport Program- Dr. Maria Raven and Courtney Gray, MSW • Q & A • Wrap-up and announcements

6. Speaker information Dr. Maria Raven Assistant Professor, Department of Emergency Medicine UCSF School of Medicine Courtney Gray, MSW Manager, San Francisco Health Plan Care Support Program

7. Progress towards the goal

8. Payer sources Notes:Other = Workers‘ comp + Prisoner care + etc; Uninsured =Self pay + Charity care + Indigent care programsSource: America's Essential Hospitals FY 2010 Characteristics Survey

9. America’s Essential Hospitals Webinar Tackling Issues for Medicaid High Utilizers October 22, 2013 Maria Raven, MD, MPH, MSc Assistant Professor of Emergency Medicine University of California, San Francisco Courtney Gray, MSW Care Support Manager San Francisco Health Plan

10. The Issue • Small percentage of patients account for disproportionate share of health care use and costs • Heterogeneous population: wide range of medical, behavioral, and social issues contribute • No “one size fits all” solution

11. Approach • Intervention is intervention • Payer may alter the way it’s carried out • 2 experiences: • New York State Medicaid funded program within public hospital system: NYC Health and Hospitals Corporation (HHC) • San Francisco Health Plan: MediCal Health Plan that administers Medicaid coverage for majority of SF safety net including SF General Hospital

12. Program 1: Public Hospital SystemHospital to Home (H2H) • SDOH-sponsored Chronic Illness Demonstration Project • One of six NY State Department of Health contracts • Intensive care management and coordination for fee-for-service Medicaid patients at high risk for frequent hospitalization • August of 2009-March 2012 • 540 patients enrolled cumulatively across 3 NYC public hospitals • Now codified as part of federal Health Homes initiative 12

13. H2H Financial Incentive • State Medicaid incentivized to finance demonstration projects that could contain costs for very high cost Medicaid enrollees not yet enrolled in managed care • State supported staff hired by HHC • Bear in mind • Under fee-for service payment model, fewer admissions=lower revenue for hospital system

14. H2H’s Mission • Find and enroll SDOH identified high-risk, high-cost fee-for-service Medicaid recipients • Predictive modeling • Goals • Reduce Medicaid expenditures (read: hospital admissions) • Improve health and social outcomes • All for $291.50 per patient, per month • “Supportive housing without the housing”* *John Billings, Professor of Health Policy and Public Service, Director of Health Policy and Management Program, NYU Wagner

15. H2H Team Composition/locus • Staffing Structure: • Social Workers supervise Community Based Care Managers (1:25 patient ratio), full-time housing coordinator, some dedicated primary care • Care Managers required to have high school degree and relevant experience • Offices (available for patient drop-ins) within 3 HHC hospitals, LOTS of field work, support groups

16. Frequency of Contact • State required minimum of 2 contacts per month, one face-to-face per quarter • In reality, teams had extensive patient contact, much more than required unless unable to find

17. Coordinating with Other Providers • Extensive in-reach (within HHC) and outreach to community organizations • MOUs in place for data sharing • Consents included multiple organizations • 24 hour on call system • For some, embedded primary care

18. Use of Technology • Predictive modeling in theory helped target the “right” patients from the start • Demo project: risk score adjustments due to under-enrollment, programs blinded to scores • Patient Alert system: automated email alerts to Care Managers • Provision of cell phones for patients in need • Program built own database, separate from the EHR: double data entry at times

19. Complexity of very high cost patients:Enrollee #1

20. Complexity of very high cost patients:Enrollee #1

21. Average monthly Medicaid costs (program costs included in post period)

22. San Francisco Health Plan • 84,000 covered lives • Contracts with multiple medical groups and the San Francisco safety net • Multiple risk arrangements • 75-80% of San Francisco MediCal population

23. Program Adaption: CareSupport • Absorbed 12,000 SPDs due to mandatory enrollment FY 2011-2012 • Limited experience managing complex patient population • Feb 2012: program expansion and restructuring • Prior: time limited phone based management

24. San Francisco Health Plan • 84,000 covered lives • Contracts with multiple medical groups and the San Francisco safety net • Multiple risk arrangements • 75-80% of San Francisco MediCal population

25. Program Adaption: CareSupport • Absorbed 12,000 SPDs due to mandatory enrollment FY 2011-2012 • Limited experience managing complex patient population • Feb 2012: program expansion and restructuring • Prior: time limited phone based management

26. SFHP CareSupport • Current Program • SFHP members identified based on prior utilization (some referrals from within SFHP) • ED and inpatient • 2 Teams: • Each comprised of 5 BA level Community Coordinators led by Social Work Supervisor • Each team manages 125-175 members at any given time (25-35 per coordinator) • Time in program (“dose”) can vary

27. CareSupport Activities • Eligible members “vetted” by coordinators with oversight of social work supervisors • Outreach via phone or in person • In-depth holistic assessment, Care Plan developed and shared • Day to day management, including: • Connecting with needed resources (appointments, food, phones, clothing, ect) • Ongoing management of chronic issues (unstable housing, substance use, mental health, low-self efficacy, ect.)

28. San Francisco Health Plan • Advantage of health plan as program lead • Comprehensive member data across uncoordinated medical systems • Access to limited behavioral health information due to carveout; however, this is shifting in January ‘14 • Flexibility to support administrative needs such as hiring and innovative interventions, compared to county health system

29. CareSupport Population: Overview • Since April 2012, 920 referrals have been open • Currently, 159 members enrolled • Demographics • Average Age: 51 years old • Gender: 50% Female and 50% Male • Housing: 5% homeless and 5% temporarily housed • Mental Health: 34% reported being treated for Mental Health • Substance Use: 24% reported being treated for substance use

30. CareSupport Population: Cohorts • Initial data shows 3 distinct groups • Long Term CareSupport: members who are enrolled more than 6 months • Short Term CareSupport: members who are enrolled 6 months or less • Unengaged: members who were never found and engaged in the program • Unengaged groups appear fundamentally different than the two engaged cohorts

31. PMPM: Per member per month

33. Critical Components for Tackling Issue of Medicaid High Utilizers • Accept that telephonic management has seen its day • Hire (and train) the right people • Team members act as champions for program, see themselves as accountable for patient outcomes • Obtain comprehensive, accurate data in advance • Outreach and evaluation purposes • Partner with community based organizations, get consent for or agreement to share information

34. Critical Components for Tackling Issue of Medicaid High Utilizers • Understand the financial arrangements and potential ROI ahead of time • Partner with others who have an incentive to remain or become invested • Experiment with technology • Cell phones, patient alert system, unified EMRs

35. Critical Components for Tackling Issue of Medicaid High Utilizers • Understand that we don’t know what works • Healthy skepticism: very little data to support successful program models • Track outcomes that will inform sustainability and spread • Decide if breaking even with good QOL and clinical outcomes is “enough” • Especially if targeting a heavy user population, consider identifying a comparison group

36. Thank you • Maria Raven: maria.raven@emergency.ucsf.edu • Courtney Gray: cgray@sfhp.org

37. Q & A

38. Thank you for attending • Upcoming webinars – see chat box for event information • 2014 Webinars – Look out for an announcement from ltiscornia@essentialhospitals.org • Evaluation: When you close out of WebEx following the webinar a yellow evaluation will open in your browser. Please take a moment to complete. We greatly appreciate your feedback! • Essential Hospitals Engagement Network website: http://tc.nphhi.org/Collaborate