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Long-Term Care Integration Project: Resetting the Context

This project explores the integration of long-term care services to create a new way to pay for care, encourage informal care, and give disabled individuals more control. It examines the Wisconsin Partnership Program as a successful example of integrated care.

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Long-Term Care Integration Project: Resetting the Context

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  1. San Diego Long-Term Care Integration Project: Resetting the Context Mark R. Meiners Ph.D. National Program Director Robert Wood Johnson Foundation Medicare/Medicaid Integration Program Planning Committee Meeting March 8, 2006

  2. Why the Interest in Long-Term Care? Fascinating array of services we fear (nursing home) and favor (home and community-based services) Often preceded by medical conditions served by primary and acute care It is very expensive yet 80% is provided by family and friends. Medicaid is a significant payer Often a catastrophic expense for individuals.

  3. Why the Interest in Long-Term Care (LTC) Reform? People are living longer. Need for LTC increases with age: ages 65-59 5.7% ages 85-69 39.8% ages 95+ 72.1% Baby boom population coming “of age.” LTC reform options exist/have been tested.

  4. Economics of Aging & Health • Can we create a new way to pay for long-term care? • Can we integrate acute and long-term care? • Can we encourage informal care? • Can we give disabled persons maximum control over the services they receive? • Long-Term Care Insurance Partnership • Medicare/Medicaid Integration Program • Service Credit Banking in MCOs • Independent Choices: Cash and Counseling

  5. Background to Medicare/Medicaid Integration Program Experiences Robert Wood Johnson Foundation 15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VT For Background and Technical Assistance Documents see: http://www.gmu.edu/departments/chpre/research/MMIP/index.html

  6. Key Dimensions of Integrated Care Program Development • Scope and flexibility of benefits - more than fee-for-service • Delivery system - broad, far reaching, options, experienced • Care integration - care teams, central records, care coordination. • Program administration - enroll, dis-enroll, integrated data & IS • Quality management and accountability - unified, broad, CQI • Financing and payment - flexible, aligned incentives

  7. Wisconsin Partnership Program (WPP) Wisconsin Family Care

  8. Wisconsin Partnership Program (WPP) Integrates all Medicaid with Medicare benefits through non-profit health plans that blend capitation payments from both these programs. Relies on a broad interdisciplinary team that includes the patient and their physician, along with a nurse practitioner, nurse, social worker, and others as needed.

  9. Family Care County based program provided capitation payment to provide managed long-term care with primary and acute services carved out and coordinate on a fee-for-service basis. Limits its integration efforts to Medicaid-only services that fall under its capitation payments. Relies on nurses and social workers to coordinate with primary and acute care services (physician, hospital, prescription drug, dental care, podiatry, vision, and mental health related services), but does not provide those services.

  10. WPP Evaluation Results The number of inpatient hospital days decreased 52% for physically disabled members in the first year after enrollment in WPP. The number of nursing home days decreased 25% for elderly in the first year after enrollment in WPP. Only about 6% of WPP members are in nursing homes compared to 26% of Medicaid recipients age 65+ across the state. By close coordination and monitoring, the WPP has been able to keep prescription drug increases in the range of 9 to12%, well below the national average of 18 to 21%. The vast majority (95%) rated the services excellent or very good.Only 5% of members disenrolled for reasons other than death or relocation.

  11. Wisconsin Partnership Program Outcomes

  12. Wisconsin Partnership Program Outcomes

  13. Family Care Evaluation Results Family Care has also recently undergone a rigorous independent review conducted by APS Healthcare (APS, 2005). The study focused on the fourth (2003) and fifth (2004) years of operation. Evaluators examined Family Care members’ health status, health care costs, and long-term care costs compared to similar individuals receiving fee-for-service Medicaid services in the rest of the state.

  14. Family Care Evaluation Results Waiting list elimination--a key selling point of Family Care--has been achieved for over three years now. Over the two-year study period, average individual monthly Medicaid costs for Family Care members outside Milwaukee were $452 lower than costs for their comparison group. Costs for members in Milwaukee were $55 lower than those for their comparison group. Source of savings: (1) a direct effect of a more cost-effective mix of service purchases; and (2) an indirect effect of improving member’s health and ability to function independently.

  15. Family Care Evaluation Results Family Care members visit their primary care physician more regularly than the comparison group. This benefit accrued across all counties and target groups. This additional attention to primary health care is thought to be related to the work of the Family Care nurse care managers. More frequent primary care physician visits appeared to provide opportunities to increase prevention and early intervention health care services that, in turn, reduced the need for more acute and costly services.

  16. San Diego Stakeholder LTCIP Vision for Elderly & Disabled • Develop “system” that: • Is consumer driven and responsive • Provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus • Pools associated (categorical) funding • Expands access to/options for care • Utilizes existing providers

  17. Stakeholder Vision (continued) • Fairly compensates all providers w/rate structure developed locally • Engages MD as pivotal team member • Decreases fragmentation/duplication w/single point of entry, single plan of care • Improves quality & is budget neutral • Implements Olmstead Decision locally • Maximizes value of federal and state funding

  18. Where are we now? • BOS: “come back with 3 options” • Network of Care • Physician Strategy • Healthy San Diego Plus (HSD+) • LTCIP/HSD+ Options • #1 – 3 year pilot w/ limited IHSS enrollment • #2 - Governor’s Proposal/Access Plus

  19. Network of Care/Aging and Disability Resource Center (ADRC) • Test/improve existing web-based system & expand to support 2 service delivery models • Funding: AoA, $610,000 over 3 years for Aging & Disability Resource Center • Expand as communication link btw MD, consumer, caregiver, community providers • Develop CQI program/Community Education Workgroup • www.sandiego.networkofcare.org

  20. Physician Strategy • Fee-for-service initiative to improve chronic care management • Partner w/physicians vested in chronic care • Develop interest/incentive for support of HCBC • Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports • On-going meetings with physicians • Implementation plan in development

  21. Key Micro Strategy: Primary Care Teamwork Focus on holistic approach encompassing health and welfare (e.g., psychosocial, economic, environmental, social supports) Monitor ongoing health status for early detection of problems Emphasize health education and prevention Support chronic care self management Increase opportunities for communication

  22. Summary Thoughts ALTCI demonstrations are learning opportunities for better care systems Best model not clear. New Medicare Special Needs Plan rules represent new opportunity and challenge. Quality improvement evaluation is necessary going forward.

  23. LTCIP Options Option #1- pilot w/ up to 1000 IHSS clients/year Option #2-Governor’s Proposal (Access Plus) • Main Features • Voluntary 3 year pilot • For Medi-Cal-only & dully eligible Aged, Blind and Disabled (ABD). Limited to 1000 IHSS clients/yr. Enrollment not capped for non-IHSS Medi-Cal ABDs • Local share (realignment $) for IHSS direct service hours continues to be sent to State; IHSS admin $ unaffected during pilot. • If IHSS client chooses to enroll in LTCIP, will request a voluntary discontinuance from IHSS, but continue to be tracked and providers paid thru CMIPS • Independent evaluation • Main Features • Voluntary 5 year pilot • For dual ABDs only • LTCIP and IHSS will be mutually exclusive. • If IHSS client opts to request voluntary discontinuance and enroll in LTCIP, personal care services will be provided under the health plan cap with no funding from IHSS or realignment • Independent Evaluation

  24. How to influence planning? • Get on LTCIP mailing list for updates • Log onto website for background & info: www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/ • Call or e-mail input/ideas: 858-495-5428 or evalyn.greb@sdcounty.ca.gov or 858-694-3252 or sara.barnett@sdcounty.ca.gov

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