Building an Integrated Care Team : ICOs & ASAPs

1. Mass Home Care The COMMUNITY LIVING Program Building an Integrated Care Team: ICOs & ASAPs November 19, 2012

2. Topics • ASAP Network Readiness to Contract with ICOs – Joan Butler, Executive Director, Minuteman Senior Services • Community Care Linkages – Amy MacNulty, Project Director • The COMMUNITY LIVING Program – Amy MacNulty

3. MA ASAPs Ready to Meet ICO LTSS Coordination Requirements and more… • Participation on interdisciplinary primary care team • RN assessments (CDS) and comprehensive functional assessment • Availability to consumers in their home and across settings • Credentialed and experienced workforce

4. As member of ICT, ASAP LTSS Coordinators will be responsible for: (Sec. 4.6D 2. Care Delivery Model) • Represent the LTSS needs of the Enrollee (a.) • Advocate for the Enrollee (a.) • Provide education on LTSS to the ICT and the Enrollee (a.) • Provide LTSS coordination, including assessments (a.) • Evaluate the Enrollee’s Individual Care Plan and monitor the plan at the Enrollee’s direction (a.) • Participate in initial and ongoing assessments of the health and Functional Status of Enrollees (b.) • Develop the community-based component of an ICP (b.) • Arranging and, with the agreement of the ICT, coordinate the authorization and the provision of appropriate community LTSS and resources (c.) • Assist Enrollees to access PCA Services (d.) • Monitor the appropriate provision and functional outcomes of community LTSS (e.) • Determine community-based alternatives to long-term care (f.) • Assess appropriateness for facility-based LTSS, if indicated (g.)

5. If Enrollee has LTSS needs, ASAP LTSS Coordinators will participate as a full member of the ICT: (Sec. 4.6D 3. & 4. Care Delivery Model) • At any time at the request of the Enrollee with LTSS needs (3.a.) • During the initial assessment (3.b.) • When the need for community-based LTSS is identified by the Enrollee or ICT (3.c.) • If the Enrollee is receiving targeted case management or rehabilitation services purchased by DMH (3.d.) • In the event of a contemplated admission to a nursing facility, psychiatric hospital, or other Institution (3.e.) • Assist in identifying a more appropriate LTSS Coordinator, if after initial assessment, it is determined that the Enrollee has specific needs outside the LTSS Coordinator’s expertise (4.)

6. ASAP LTSS Coordinators will meet qualifications established by ICO, at a minimum: (Sec. 4.6D 5. Care Delivery Model) • A Bachelor’s degree in Social Work or Human Services, or at least two years working in a human service field with individuals with disabilities (a.) • Completed training that includes education on person-centered planning and person-centered direction (b.) and the independent living philosophy • Experience and expertise in working with people with disabilities and/or elders in need of independent living supports and LTSS (c.) • Knowledge of the home and community-based service system and how to access and arrange for services (d.) • Experience in conducting needs assessments for LTSS needs and with monitoring LTSS delivery (e.) • Cultural Competence and the ability to provide informed advocacy (f.) • Ability to write an Individualized Care Plan and communicate effectively, verbally and in writing, across complicated service and support systems (g.) • Met all requirements of their ASAP employer (h.)

7. MA Executive Office of Elder Affairs “For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives.” – Secretary Kathleen Sebelius • ASAP network has been time-tested, and proven to be deserving of the public trust for the responsibility of operating the Commonwealth’s Home Care Program. • As delegated agents of the Executive Office of Elder Affairs, the ASAPs collectively offer a common suite of Home and Community Based Programs and Services from border to border. • Programs are operated with statewide standards and procedures to ensure consistent quality. • However the governance design also allows for the necessary degree of local customization which is inherent and necessary with the delivery of home and community based services.

8. MA ASAPs History & Mission Established in 1974 by state law to create community alternative to nursing home care for low income MA residents 60+ who needed assistance with ADLs (coordinate services on behalf of Medicaid eligible members 60+,Chapter 19A,4B) Unique statewide infrastructure for home and community based care with 40 years experience serving people with chronic care needs and their caregivers over the long term

9. MA ASAP History & Mission Con’t • Functional orientation to independent living in the community over the long term • In MA – home care (certified) and home care (ADL assistance) • Embrace consumer choice and empowerment • Well positioned to assist consumers to integrate healthy lifestyle and compliance with medical instructions into daily living • Largest conduit of state and federal funding for long term services and supports delivered to local communities • Evolved as single entry point to wide range of in home and community based options and supports for broad population of seniors, disabled adults and caregivers

10. Who are the MA ASAPs? • 27 Not for Profit organizations who are members of Mass Home Care • Statewide network that covers every city and town • Located in communities served • Members of community on Board of Directors • Specialize in assessment and care coordination & SNF Diversions and managing a vendor network • Standardized assessment tool and client data system

11. ASAPs serve every city & town

12. FY11 ASAP Spending ~$340m On Behalf of MA Executive Office of Elder Affairs

13. ASAP Programs & Services Community-BasedSupports Evidence Based Programs • Home assessments of a person's functional ADL's & IADL's • Cognition, Depression and Nutritional Screening • Home Safety Assessment • Advance Directives • Caregiver supports • Authorize, purchase and monitor home & community-based services (extensive vendor network) • Medication management assistance • Nursing Home Pre-Admission Screenings • Counseling on Community Options • Money Management • Elder Abuse & Neglect Investigations and Intervention • Referrals to wellness/disease prevention resources • Care Transitions ( Coleman Model ) • Patient Centered • Interdisciplinary • Addresses continuity of care across settings and practitioners • Uses Personal Health Record • Teaches Self Management • Healthy Living Programs • Chronic Disease Self Management (Stanford Program) • Diabetes Self Management • Arthritis • Chronic Pain Management 2013 • Mental Health and Depression • Matter of Balance Fall Prevention • Healthy Eating • Power Tools for Caregivers 13

14. Model of Home CareIndependent Care Management Plus Vendor Network* with 1,400 contracts statewide • Personal Care Assistance • Homemaking & Home Chores • Laundry & Grocery Shopping • Home Health Services-Skilled RN, OT, PT, Speech Therapy • Supportive Home Care Aide • Adult Day Health Care • Alzheimers Day Programs • Habilitation Therapy • Safe Return Wander Locator • Meals on Wheels • Transportation • Personal Emergency Response • Medication Dispensing System • Adaptive Housing/Assistive Technology • Short term residential respite in Nursing Facility, Assisted Living • In Home Respite • Mental Health * Vetted and monitored for compliance and quality

15. ASAPs offers information and referral for consumer education & access to local and statewide services • Public benefits, food stamps/fuel assistance • SHINE • Private Pay services • Housing options • Transportation • Groceries/Pharmacies that deliver • Senior Dining • Senior Centers/COAs • Support Groups • Employment • Nursing Home Ombudsman • Assistive Technology • Assisted Living Facilities • Nursing Facilities • Elder Law Attorneys • Driving resources • Disease specific resources: Alzheimers, MS, ALS, Parkinsons • Fact Sheets/Seminars • Life long learning • LGBT resources

16. ASAP Consumers Served Annually • Over 100,000 calls for Information and Referral • 69,000 seniors received Care Management & in home and community based services (14,500 were nursing home level of care) • 75,000 received Meals on Wheels or community nutrition services • 50,000 Nursing home screenings to assess potential for return to the community and transition assistance • 24,000 SCO members served by ASAP GSSCs • 550+ consumers received Options Counseling services

17. Serving adults of all ages with disabilities and their caregivers • Since the 1980s, ASAPs have coordinated MassHealth services that serve adults with disabilities. • 14 of the ASAPs are Personal Care Management Agencies (PCMs) • 10 of the ASAPs manage Adult Foster Care programs • 12 of the ASAPs manage Group Adult Foster Care (GAFC) • Founding partners of MA Aging and Disability Collaborations (ADRCs)

18. ASAP Workforce Capacity & Expertise • Care Coordinators/Care Managers (944) • RNs (265) • RN Supervisors (39) • Total Employees (3,351) • ASAP staff are culturally and linguistically diverse to match the needs of the community (ASAP Case Staff speak 55 languages and translators available in all areas) • Expertise in services for elders and adults with disabilities and chronic conditions • Experience and expertise in person-centered care, consumer engagement and the independent living philosophy • Experience in managing a capitated system for a fee for service network

19. ASAPs Alternative to Nursing Homes Staying Home: (ECOP/Choices) ASAPs manageprograms targeted at people who meet the clinical criteria for the nursing home level of care. • 10,248 elders per month are not in nursing homes in MA today because of ASAP services • Results: $266 million annual savings Returning Home: (CSSM) ASAP staff visit nursing homes toscreen elders on a pre-admission and post-admission basis • to determine their ability to return home • to design a care plan to transition to home • to avoid NF placement at the beginning

20. Money Follows the Person Initiative • Between July 12, 2011 and June 30, 2012, 168 people have been transitioned out of nursing homes. Another 86 people are enrolled in the program but have not yet been placed. • Of those 168 placements, 125 (74.4%) were elders placed by ASAPs. • 19 (11.3%) were DD/ID, 22 (13.1%) were physically disabled, and 2 (1.1%) were MH clients.

21. SCOs & ASAPs: Template for ICOs Geriatric Support Service Coordinators are members of the primary care team who: • mayassess all enrollees upon enrollment • coordinate community support services with the agreement of primary care team • coordinate non-covered services (housing, home-delivered meals and transportation) • monitor outcomes & track enrollee transfer • review enrollee care plans ASAPs currently manage Vendor Network for 3 SCOs : • Long term services and supports

22. Community CareLinkagesSMA Division of Mass Home Care Community Care Linkages is a strategic initiative to effectively integrate services of the Massachusetts Aging Services Access Points (ASAPs) into the evolving healthcare delivery system. • 2+ years of Collaboration & Partnering in response to Health Reform Initiatives • CCTP/Section 3026 • Pioneer ACOs • PCMHs/Physician Practices • Self Management Supports/CDSMP • ICOs • The COMMUNITY LIVING Program

23. MA ASAPs Involved with multiple Innovation Center Initiatives Primary Care Transformation • Comprehensive Primary Care Initiative (CPC) • Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration • Independence at Home Demonstration ACOs • Medicare Shared Savings Program • Pioneer ACO Model • Advance Payment ACO Model • PGP Transition Demonstration Bundled Payment for Care Improvement • Model1: Retrospective Acute Care • Model 2: Retrospective Acute Care Episode & Post Acute • Model 3: Retrospective Post Acute Care • Model 4: Prospective Acute Care • Capacity to Spread Innovation • Partnership for Patients • Community-Based Care Transitions • Million Hearts • Innovation Advisors Program • Health Care Innovation Challenge Initiatives Focused on the Medicaid Population • Medicaid Emergency Psychiatric Demonstration • Medicaid Incentives for Prevention of Chronic Diseases • Strong Start Initiative • Dual Eligible Beneficiaries • State Demonstration to Integrate Care for Dual Eligible Individuals • Financial Models to Support State Efforts to Integrate Care • Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents

24. CMS Payment to MA ASAPs for Care Transition Services at part of CCTP 47 partners announced in three rounds, 4 in Massachusetts • Elder Services of Berkshire County • Berkshire Medical Center and the Berkshire Visiting Nurse Association • Elder Services of Worcester & BayPath Elder Services • MetroWest Medical Center; St. Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital • Somerville-Cambridge Elder Services & Mystic Valley Elder Services • Cambridge Health Alliance and Hallmark Health System • Merrimack Valley of Massachusetts and Southern New Hampshire Elder Services • Anna Jacques Hospital, Saints Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital http://innovation.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html

25. http://www.healthyliving4me.org

26. The COMMUNITY LIVING Program The Community Living Program is offered exclusively through Mass Home Care and offers beneficiaries of ICOs, ACOs, PCMCHs, and other care provider organizations access to a wide range of vetted home and community based supports, including care coordination, member education and engagement, and registered nurse assessments. Statewide network of ASAPs are aligning with local and national trends towards integrating aging and disability services.

27. The COMMUNITY LIVING Program for ICOs* Member-Centered Long Term Services for Dual Eligibles: • Statewide network • Successful partnering with community agencies and medical providers • ILCs, ADRCs, SCOs, ACOs, PCMHs, FQHCs • Key Services • Initial Assessment • Basic Coordination • Complex Care Coordination • RN Assessments • Network Management • Evidenced-Based Healthy Living Programs • Care Transitions Coaching A Mass Home Care Initiative for Integrated Care Organizations Putting the pieces together *Refer to handout for narrative

28. LTSS Coordinator • Initial Assessment • In-person, comprehensive initial assessment (CDS/MDS-HC) • Assess functional status (ADLs) • Determine formal and informal supports • Care Coordination • Conduct Comprehensive Person-Centered Assessment • Develop Care Plan • Engage Informal Supports • Assess Risk and Care Team Management • Coordinate Services Across Care Continuum • Assist with Nutritional Plan of Care • Care Transitions Coaching

29. ASAP RN Assessments • Experience with initial and on-going assessments (CDS/MDS-HC) • Conduct assessment and plan of care for personal care (non-PCA) • Complete PCA evaluations

30. Network Management • 30+ years experience with successful management of vendor network • Employ standard statewide protocols for contracting, monitoring, quality, compliance • Respond to ICO needs to develop/expand services and programs

31. Evidence Based Health Living Programs • Chronic Disease Self Management (Stanford Program) • Diabetes Self Management • Arthritis • Chronic Pain Management 2013 • Mental Health and Depression • Matter of Balance Fall Prevention • Healthy Eating • Power Tools for Caregivers

32. Matrix of ASAP Statewide Capacity* *Refer to handout for complete matrix

33. What ASAPs can offer your members: • LTSS Coordination • Initial Assessment (CDS/MDS-HC) • Basic Coordination • Complex Care Coordination • RN Assessments • Network Management • Nursing Home Screening • Evidenced-Based Healthy Living Programs • Care Transitions Coaching • Caregiver supports • Authorize, purchase and monitor home & community-based services (extensive vendor network) • Medication management assistance • Counseling on Community Options • Money Management • Elder Abuse & Neglect Investigations and Intervention