Long Term Care The Texas Experience: Overview

1. Long Term CareThe Texas Experience: Overview San Diego County LTCIP Planning Committee October 26, 2001 Cindy Adams

2. What is STAR? • A managed care delivery system • Objectives: • Emphasize early intervention • Promote improved access to quality care • Improve health outcomes for the targeted population, with a special focus on prenatal and well child care • Targeted Members: • Individuals receiving Temporary Assistance to Needy Families (TANF) and TANF related benefits

3. What is STAR+PLUS? • A managed care pilot project for the SSI and SSI-related population • Dually eligible members enrolled for LTC services only • Build on the STAR Program

4. Why STAR+PLUS? • SCR 55: Requires a cost-neutral long term care integrated model • New challenges: • Increasing cost of long term care • More people with chronic conditions • Fragmented delivery: Acute and long term care

5. STAR+PLUS - 1915 (b) and (c) • 1915 (b) - Waives freedom of choice to allow mandatory participation • 1915 (c) - Allows additional services for 1915 (c) waiver eligibles • Encourages HMOs to add waiver services as value added services • Provides more alternatives

6. STAR+PLUS Objectives • Integrate acute and long term care into managed care system • Provide the right amount and type of service to help people stay as independent as possible • Serve people in the most community-based setting consistent with their personal safety • Improve access and quality of care • Increase accountability for care • Improve outcomes of care • Control costs

7. Harris Choices: Required STAR+PLUS Groups • Medicaid only clients • Choice of HMOs • If client does not choose, default to HMO • HMO - Both acute and long term care

8. Harris Choices: Required STAR+PLUS Groups • Dual Eligible (Medicare/Medicaid) • Choice of STAR+PLUS HMOs • If client does not choose, default to HMO • STAR+PLUS HMO is responsible for long term care services. Client may choose HMO or traditional Medicare for acute care

9. People Not in STAR+PLUS • Excluded • Clients residents of Intermediate Care Facilities for the Mentally Retarded (ICF/MR) • Clients not eligible for full Medicaid benefits • Undocumented aliens • Children in state foster care • Nursing facility residents • In nursing facility when become eligible • 120 days after admission to nursing facility (enrolled STAR+PLUS members)

10. STAR+PLUS Plans • Competitive procurement process for HMOs • HMO Blue • Amerigroup • Texas Health Network(PCCM)

11. STAR+PLUS Enrollment 10/1/01 56,569 Total 27,357 Dual Eligibles 29,171 Medicaid Only

12. Harris County Estimated STAR+PLUS Clients FY’01

13. STAR+PLUS Services • Primary, preventive and acute care (doctor, hospital, lab, x-ray) (Medicaid only) • Mental health and substance abuse services (Medicaid only) • Personal care services • Adult day health services • Nursing facility services • Care coordination • Waiver services (therapy, respite, adult foster care, assisted living, adaptive equipment, in-home modifications) • Value-added services (adult dental services, waiver services for non-waiver clients)

14. Behavioral Health Services • Screening, diagnosis, treatment • Hospital inpatient - MH/SA • Licensed Master’s Social Worker (LMSW - AP) • Licensed Professional Counselor (LPC) • Psychology • Psychiatry • Psychiatry Hospital Inpatient (under 21 years of age) • Value-added services

15. HMO Blue STAR+PLUS Value Added Services • Toll-free medical help line 24 hours a day, 7 days a week • Dental care for adults • More choices in eyeglass frames • Extra services if approved and medically necessary: • Home delivered meals • Medical equipment • Assisted living/foster care • Emergency alert systems • Relief for your caregiver • Home/community-based services (non-emergency transportation when no other source is available)

16. Care Coordination • HMO required to contact members within 30 days of enrollment • HMO makes home visit and assesses members needs, as appropriate • HMO assigns a care coordinator (or coordination team), as appropriate

17. Care Coordinator Member Family or Representative PCP Care Coordination Model • Who • RN or licensed Master’s level social worker (with specific cultural and linguistic expertise) • Responsibilities • Coordinator, facilitator, investigator, liaison, advocate, empowered to authorize services • Leads team of service providers • Close collaboration with medical providers, patient, and family • Knowledge of TPL/Medicaid/Medicare resources Summary: Care Coordinators are the key to establishing a comprehensive, individualized Plan of Care to serve the member in the least restrictive environment, with the most quality oriented, cost effective care/services.

18. Level I (Routine) • Major Functions • Telephonic care coordination • Member education • ICP (individual care plan) with short term needs • Respite care, 1x only DME services, etc. • Monthly member transitions • Assignment Criteria • New enrollment of Non-CBA, DAHS (Day Activity and Health Services) or NF members • No LTC services • Assignment by regions • Stable population with episodic support and periodic assessment

19. Level II (Moderate) • Major functions • Team based approach/associates assigned to care coordinator • Combination of field and telephonic care coordination • Telephonic assistance from care coordinator associates • ICPs/goals • Member education • CBA upgrade (if appropriate) • Assignment criteria • HHN = < 1 visit per month • PAS = below 120 units per month • DAHS member • ER/hospital = < 1 in 6 months • Ongoing medical supplies • Basic LTC type services

20. Level III (Intense) • Major functions • Team based approach/associates assigned to care coordinator • Combination of field and telephonic care coordination • Telephonic assistance from care coordinator associates • ICPs/goals and outcomes • Member education • MDS NF/HC (which ever appropriate) • Assignment criteria • CBA or NF member • Ventilator or dialysis dependent • HHN > 1 visit per month • PAS > 120 units per month • ER/hospital > 2 visits in 6 months

21. Most Restrictive Least Restrictive Specialty Unit within a nursing facility Skilled Nursing Facility Adult Care Home Adult Foster Care Home Personal Care Home Assisted Living/ Residential Care DAHS Home or Apartment Full Continuum of Placement Options for Those Individuals Requiring Long Term Care

22. STAR+PLUS Quality • Quality improvement plan (from HMOs) • State contractor - Texas Health Quality Alliance • Consumer surveys and consumer focus groups • Provider satisfaction survey • Focused studies • Access to care • Targeted studies on care coordination and behavioral health care • Utilization management

23. Evaluation Criteria • Consumer satisfaction • Integration of care • Access to care • Quality of care • Emphasis of community based care • Impact on budget • Impact on providers

24. Consumer Satisfaction • 60% of consumers experience no problem getting the care they need, when they need it • 52% of consumers receive the care they need without long waits • 65% of consumers indicate their doctor communicates well with them • 71% feel office medical staff treats them with courtesy, respect, and helpfulness • 56% experience no problem getting special medical equipment • 65% of consumers experience no problem getting all the home health care needed

25. Challenges • Enrollment • Medicaid population • LTC providers transition • Computer systems • Dual eligibles

26. Opportunities • Early intervention • Disease management • Care coordination • Home visits • Integration of care • Flexibility in service delivery