Illinois Health Connect and ED Care Coordination

1. Illinois Health Connect and ED Care Coordination Illinois Health Connect Provider Services 1-877-912-1999 mkirkegaard@automated-health.com

2. Outline of Presentation Overview of Illinois Health Connect and Medical Home model Client Services Outreach to Providers IHC Outcomes Opportunities to Impact ED Use Nurse Consultation Line Claims History Tool Care Coordination with PCP PCP Verification

3. Illinois Health Connect: Primary Care Case Management Based on concerns regarding access to care , need for improved coordination of care and quality improvement, Illinois Department of Healthcare and Family Services convened a series of stakeholder meetings and selected a program of health reform based on primary care case management or the medical home model. The program started in 2006 and is called Illinois Health Connect. The program is administered by Automated Health Systems.

4. Medical Home American Academy of Pediatrics Definition: “A medical home is a community-based primary care setting that integrates quality and evidence-based standards in providing and coordinating family-centered health promotion in wellness, acute and chronic condition management.” Starfield and Shi, Pediatrics 2004;113:1493-1498: “International and with-in nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reduction of disparities in health…”

5. Illinois Health Connect (IHC) Participating PCPs or “medical homes” There are 2 million of total 2.6 million Illinois Department of Healthcare and Family Services (IDHFS or HFS) clients eligible, and can choose based on the county of residence a Managed Care Plan such as Harmony, Meridian or Family Health Network or Illinois Health Connect. Currently the IHC has a network of 5,700 participating “Medical Homes” including family doctors, pediatricians, internists, rural health clinics and FQHCs with capacity for 5.4 million clients Agree to meet certain quality standards like 24/7 access Receive a monthly care management fee per client. Receive an enhanced fee schedule for participating PCPs. Certain groups such as Medicare/Medicaid or DCFS kids are excluded from IHC. IHC Functions like a “health plan” to ensure high quality care

6. Medical Home Quality Standards IHC PCPs must have adequate office hours to accommodate pt care Solo PCPs: 24 hours per week Group PCPs: 32 hours per week More evening hours associated with less ED use IHC PCPs must have 24/7 availability for pt advice

7. IHC: Client Enrollment Eligible clients have 60 days to select a PCP. Clients receive 3 mailings and several outreach phone calls to assist them in this process. Clients who do not make an active choice for a PCP are “auto-assigned” based on claims data, PCP of family members and geography. Clients must see their PCP/medical home for primary care. Specialist, who do not participate with IHC as a PCP, do not require a referral for care from the PCP at this time.

8. IHC: Client Services The Client Call center Handles up to 80,000 calls per month Assist eligible clients with selecting a PCP or medical home through the call center, website and mailed forms. (assist excluded patients in locating a PCP. ) Assist with access to subspecialty care Assist with making well-child appointment if due Educate clients on the medical home concept Send semi-annual newsletters to IHC clients Send reminder letters for both child and adult preventive care

9. Provider Outreach “High Touch” outreach to providers Provider Service Representatives and QA nurses make approximately 350 visits to provider offices per week to assist with billing/coding; IHC administration; Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) standards; and clinical quality improvement. Five advisory subcommittees meet quarterly and create opportunity for stakeholder input Information provided via quarterly newsletters, blast fax, IHC website, and monthly webinars.

10. IHC Outcomes Improved access to primary care High client satisfaction (>95%) Based on IHC provider Survey over 92% of providers feel that IHC is beneficial for patients IHC has saved $220 million over past two years Decreased ED utilization and hospitalizations Improving clinical metrics such as rates of adolescent check-ups, mammograms and developmental screening

11. After Hours Nurse Consult Line In circumstances when pt cannot reach their PCP after hours, IHC provides an afterhours nurse consult line. Available 7 pm to 7 am weekdays and 24/7 on weekends. Call 1-877-912-1999 If pt is directed to ED by a nurse, a letter is sent informing PCP of the ED visit.

12. Pt Education about ED Use Necessary Client survey results: 759/797 (95%) know name of PCP 365/797 (46%) had used ED in past year 204 pts indicated that they had not contacted their PCP for advice first 127/204 (62%) indicated that “it was too much of an emergency” to contact PCP first Understanding when to go to ED appears to be most significant factor in ED use

13. Actionable Drivers of Unnecessary ED Use Access to specialty care IHC Call Center can assist both pts and providers in accessing specialty care Pain Management Recommend strict pain/narcotics contracts References available through IHC website under Clinical Resources Dental care “Restorative” dentistry for adults is a covered service Contact Dentaquest at 1-888-286-2447

14. IHC Claims History Available to any Medicaid provider through HFS’ Medical Electronic Data Interchange (MEDI) System. Need to obtain a user name and password. Includes compilation of all HFS paid claims for each HFS client for past two years. Includes immunizations and pharmacy data For complete instructions on MEDI registration go to www.illinoishealthconnect.com under Provider Information or contact IHC for assistance.

15. HFS’ MEDI Registration Users must register with MEDI (Medical Electronic Data Interchange) System Providers, payees, other business and their employees may register for specific functions Providers must enter information exactly as it appears on their “Provider Information Sheet”, which is generated by HFS when the provider registered MEDI “administrator” at each clinic site can assign usernames/passwords to each staff person

16. Accessing IHC Provider Portal Link

17. Illinois Health Connect Provider Portal

18. Claims History Report Contents Prescription Summary (2 years of data) Prescription Date Prescription Quantity Prescription Description Immunization Summary (currently 4 years of data, will expand to 7 years) Immunization Date Immunization Code Immunization Description Claim Summary (2 years of data) Service Date Claim Date Provider Name Diagnosis Code Procedure Code Claim Type

19. IHC Claims History Screen Shot

20. IHC Claims History Screen Shot

21. Care Coordination All IHC eligible clients have a PCP/medical home. Providers can identify the PCP/medical home by: Using the “Who’s My PCP?” function on the IHC website at www.illinoishealthconnect.com Using eligibility systems such as MEDI or REV vendor Calling IHC Provider Service Helpdesk at 1-877-912-1999; M-F 8 am to 7 pm. IHC can assist clients who are not eligible in finding a medical home

22. “Who Is My PCP?”

23. Verifying the PCP at the time of service: using MEDI

24. IHC Summary The cornerstone of the Illinois Health Connect program is getting every client linked to the “best fit” medical home for ongoing care. IHC has additional services such as Nurse Consultation Line and specialty referral to assist clients. Claims History available to all Medicaid providers. Care coordination through the medical home is key. Providers outside the medical home need to identify the PCP/medical home and refer pt back. More info? Call: 1-877-912-1999 or www.illinoishealthconnect.com