Download
1 / 40
400 likes | 415 Views
Wisconsin has implemented comprehensive health and long-term care programs that provide Medicaid-eligible individuals with choice and the ability to live at home. This program improves outcomes, engages members in decision making, and reduces costs.
E N D
Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004
Wisconsin Has Implemented Health/ Long-Term Care Programs That: • Provide Comprehensive Health & Long-term Care to People Who Meet Nursing Home Admission Criteria & are Medicaid Eligible; • Allow Consumers to Retain Choice of Primary Care Physician; • Maximize the Ability of Consumers to Live in Their Own Home & Participate in Community Life.
Wisconsin Has Implemented Health/ Long-Term Care Programs That: • Improve Functional & Clinical Outcomes; • Engage Members in the Decision Making Process About Their Own Care; • Minimize Reliance on Institutional Care; • Reduce Costs by Lowering the Need for Acute Care Intervention by Providing Consistent Primary Care.
The People Served Are: • Medicaid Eligible or Dual Eligible for Medicare and Medicaid • Diagnosed With an Average of 12.7 Different Conditions • Taking 13.7 Different Medicationson Average • In Need of Skilled Nursing Intervention
Wisconsin Has Implemented Two Programs Fully Integrate Medicare and Medicaid Services • Program of All-Inclusive Care for the Elderly (PACE) • The Wisconsin Partnership Program
Key Distinctions BetweenPartnership & PACE • PACE Members: • Attend a Day Center & Receive Most Services There; • Receive Care by the On-site PACE Physician; • Are Elderly. • Must Be Residents of a Large Urban Areas Capable of Supporting a PACE Site.
Key Distinctions BetweenPartnership & PACE • Partnership Members: • Select a Primary Care Physician From a Contracted Provider Network; • Receive Most Services in Their Home; • Can Be Frail Elderly or Have a Physical Disability; • The Partnership Nurse Practitioner Serves As Team’s Primary Care Representative & Accompanies the Member to Most MD Appointments; • Partnership Works in Both an Urban & Rural Setting.
Funding forPartnership & PACE • Both Medicare and Medicaid Benefits are Capitated and Paid to the Contractor • The Medicare Capititation is the Rate Book Multiplied by a 2.39 Risk Adjuster. (90%in 2004) • Risk Adjusted Rate Based on CMS-HCC and Frailty Adjuster (10%in 2004) • The Same Rate Setting Methodology is Used for Both PACE and Partnership
Funding forPartnership & PACE • Medicaid Capitation is Calculated by Discounting a Blended Average Cost for Nursing Home Care and Home and Community Bases Waiver Programs Costs. • Rates are Risk Adjusted for Age, Medicaid Only or Dual Eligible Status, and Level of Care. • The Rates for Elderly and People with Physical Disabilities Differ Significantly. • The PACE and Partnership Rates Differ Slightly Based on Case Mix
PMPM Comparison--Average WPP & January 1999 Waiver Population
How Partnership Works • Wisconsin Contracts with 4 Community Based Organizations to Provide Partnership Managed Care. • Elder Care of Wisconsin • Community Living Alliance • Community Care Organization • Community Health Partnership
How Partnership Works • Partnership Organizations are at Full Risk for All Health and Long-Term Care Outcomes. • Both Medicare and Medicaid Capitation Payments are Made to the Organizations. • The Partnership Organizations Subcontract with Various Providers including Primary Care Physicians and Hospitals and Pay Them on a Fee-For-Service Basis
How Partnership Works • Care is Coordinated Through an Interdisciplinary Team which includes: • The Member • Primary Care Physician (PCP) • Nurse Practitioner (NP) • Registered Nurse (RN) • Social Worker
How Partnership Works • The NP Meets with the PCP to Establish a Collaborative Practice Agreement that Often Leads to the Delegation of Primary Care to the NP. • The NP Acts as the Liaison Between the PCP, the Member and the Remainder of the Team. • RNs Provide Both Care Management and Skilled Nursing Care. • Social Workers Provide both Psychosocial and other Supportive Services as Necessary
How Partnership Works • Provides Prevention Services to Minimize the Need for Inpatient and Emergency Room Care. • Provides Community Based, Supportive Services to Minimize the Need for Nursing Home Care. • Accompanies the Member to Physician Visits and “Translates” Physician Recommendation for the Benefit of the Member and the Team.
How Partnership Works • Assures that Member Concerns and Preferences are Understood. • Assures Follow Through with Physician Recommendations. • Promotes Quality of Life by Supporting Member Specified Outcome.
Measuring Outcomes of the Partnership Program • The Department of Health and Family Services is using several methods, both traditional and innovative, to measure quality& effectiveness: • 14 Member Outcomes Based on Member’s Input about his/her Quality of Life; • Incidence of ACSCs (ambulatory care sensitive conditions); • Utilization of Inpatient Hospital & Nursing Home Care Before & After Partnership.
14 Member Outcomes • Developed by the Council on Quality and Leadership, a national accreditation agency for community disability programs. • Determines whether: members’ desired outcomes are being met, and the support the member needs to achieve the outcome has been put in place by the team.
Health Care Outcomes Staff Compile & Trend Data On Hospitalizations For Ambulatory Care Sensitive Conditions (ACSC): ACSCs are defined by the Institute of Medicine as conditions for which good access to primary care should reduce the need for hospital admissions.
Result:Hospital Admission The Rate of Hospital Admissions for Ambulatory Care Sensitive Conditions Decreased by 41.1 % from 2000 to 2002.
Result: Access to Dental Care Access to Medicaid funded dental care remains difficult in Wisconsin. For example: • 17% of home and community-based waiver programs’ for elderly and people with physical disabilities had dental visits in 2001. • 72% of all participants in PACE and Wisconsin Partnership program had dental visits in 2001.
Result: Health Care Utilization • Using the Hospital Discharge Data Base, Staff are Able to Demonstrate Pre/Post Enrollment Hospital Utilization • Findings Show a Positive Reduction of Inpatient Hospitalization & Nursing Home Use
Comparing Hospital Use, Same People Before & After Enrollment
Comparing Nursing Home Use, Same People Before & After Enrollment
Physician Satisfaction • Survey Completed in April 2004. • 40 % of Surveys Returned • Statistically Significant • 95% Confidence Level
Areas Needing Improvement • Member, Quality of Life, Outcomes. • Further Impact on the Incidence of Hospitalizations for ACSC. • Comprehensive Evaluation. • Demonstration of Cost Effectiveness. • Provider Satisfaction. • Interventions in Cases Where there is Mental Heath and/or Chemical Dependency Concerns.
Conclusion • Partnership offers a viable alternative to PACE that can be applied to people with physical disabilities and people who live in a rural setting. • Partnership effectively delivers member-specified outcomes. • Partnership is demonstrating positive health care outcomes.
