San Diego LTCI Project

1. San Diego LTCI Project Timothy C. Schwab M.D. CM/IO January 12, 2005

2. Meeting Objectives • Overview of SCAN History • Overview of Social HMO Model • Roles of Information Systems • Physician Network Roles • What should be measured?

3. Mission and Vision • SCAN will become a leading geriatric-focused health management enterprise in the country. Its mission is to continue to find innovative ways to enhance seniors’ ability to manage their health and to continue to control where and how they live. • We will achieve this mission by developing partnerships that allow us to deliver the right healthcare, in the right setting, and at the right cost while maximizing the seniors’ ability to remain independent.

4. SCAN History • 12 Passionate Seniors • 1977 – Long Beach Geriatric Health Care Council • Jointly developed by the City of Long Beach and Andrus Gerontology Center (USC) • 1978 – Senior Care Action Network (SCAN)

5. SCAN History (Programs) 1980 – MSSP (still largest in state) 1982 – Selected as Social HMO Site 1985 – Linkages Program 1985 – Social HMO Operational 1994 – SMART CARE (Commercial HMO) (Medicaid HMO)

6. SCAN History (Recent Programs) • ESRD Capitated Demo (pending) • CM Frail Parents of Disabled Adults • CM Study of Frail Released Inmates • CM Older Spanish Speaking Adults with Mental Health Issues • Exploring PACE Affiliation • San Diego LTCI Program

7. Social HMO • Goals • Identify frail • Coordinate social and medical services in senior HMO • Prevent long term NH placement • Integrate federal, state, and private funding

8. Social HMO • Demonstration Waivers • Funding – 100% AAPCC NHC paid more / healthy less • Quque NHC enrollment till 1997 • HCBS benefits only for NHC • No NH enrollment • Only enroll over 65 y.o.

9. Social HMO • Independent Living Power® • Personal Care Coordination • Homemaker Services • Personal Care • Home Delivered Meals • Respite Care (Home and Institutional) • Emergency Response System • Transportation

10. Social HMO • Mandated Benefits for All Members • Medicare Benefits • Pharmacy • Hearing • Vision

11. Social HMO • Operations • Annual self report assessment • In home assessment for high risk • Case manager for NHC with care plan • All network HMO activities

12. SCAN Health Plan Statistics

13. SCAN Health Plan Statistics • Average Age – 78 • Centenarians – 90 • 10th Largest Medicare HMO in country

14. HOS Comparisons 2003: An Older, Frailer Population

15. HOS Comparisons 2003: An Older, Frailer Population

16. HOS Comparisons 2003: An Older, Frailer Population

17. Information Systems • Standard HMO Systems • Enrollment (Medicare and Medical) • Eligibility (for all providers and plans) • Member Services • Provider Network/ Contract management • Claims payment • Pharmacy management

18. Information Systems • Case Management Systems • Medical Utilization/ Authorizations • Screening tools • Assessment tools • Wireless for in home use • Care plan generation

19. Information Systems • Risk Identification/Stratification • Targeting for interventions • Data vault information • Claims/encounters • Pharmacy • Lab results • Survey results • Member demographics • Purchase vs build

20. Information Systems • Management Tools • Tracking Metrics • Decision Support Systems • Regulatory reporting systems • Quality measurement reports (HEDIS)

21. Physician Network • Network vs Direct Contracting • Credentialing • Hospital based physicians • Grievance and appeals processes • Capitation vs FFS • Relationship with case managers • Quality and guideline compliance • Regulatory compliance (DHS vs CMS)

22. Was it Successful? • What should be measured? • Financial? • Functional? • Medical? • Processes? • Enrollment? • Satisfaction?