San Diego Long Term Care Integration Project

1. San Diego Long Term Care Integration Project Planning Committee Meeting May 9, 2007

2. Mrs. C • 84 year old woman lives alone • CHF, HTN, diabetes, hearing and vision loss, IADL dependencies • 16 medications by 6 MDs • Medicare and Medi-Cal beneficiary • Only child lives in Chicago

4. Your Health Records Today Healthcare Providers Personal Health Records – Files in a drawer Mail or Fax Hospital Records (Electronic) Primary Care Physician Records (Paper) Laboratory Records (Electronic) Payer Paper Records (“Explanation of Benefits”) Orthopedic Records (Paper) Endoscopy Physician (Electronic) Dental Records (Electronic) Public Health and Research Records Mail or Fax Radiology Records (Mixed) Pharmacy Records (Elec.)

5. Ideal System In-HomeServices PrimaryCare AcuteHospital MealsService MRS. C. DayHealthCare Transit Medical Specialty SkilledNursingFacility Mrs. C & Care Manager Journal of the American Geriatrics Society, Feb. 1997

6. San Diego Stakeholder LTCIP Vision for Elderly & Disabled • Develop “system” that: • provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus • pools associated (categorical) funding • is consumer driven and responsive • expands access to/options for care

7. 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 federal and state funding

8. Prior Board of Supervisors Action • Support of planning with 20% match since December 1998 • State total: $723K; County: $145K + • 2003: Continue developing HSD+ model, but come back w/options other than mandatory managed care • Since then: Strategy development: • Network of Care/Aging & Disability Resource Connection • Physician Strategy • Healthy San Diego Plus (HSD+)

9. HSD+ Update • Discussions continue with LTCIP staff, local legislative analyst’s office, State Department of Health Services re: HSD+ demo in San Diego • Will update stakeholders when new information is available

10. Network of Care/Aging & Disability Resource Connection (ADRC) • Test/improve existing web-based system & expand to support 2 service delivery models • Funding: AoA/CMS, $610,000 over 3 years for “one-stop shop” ADRC, + new $85,000 • Expand as communication link between MD, consumer, caregiver, community providers • Develop continuous quality improvement process • www.sandiego.networkofcare.org

11. Fast, Friendly, Easy Access NOC Website A2i AIS Call Center ADRC • www.sandiego.neworkofcare.org/aging • Local Service Directory • Library of articles • Assistive Devices database • LTC Options Counselor • My Folder (PHR) • Legislation tracker • 1-800-510-2020 • I&R/A to local programs and services • Screening & Intake for care management programs, APS, IHSS, Senior mental Health Team • 1-800-300-4326 • www.a2isd.org • I&R for disability-specific issues • Supportive Housing • Assistive Technology • Independent Living Skills • Advocacy www.sandiego.networkofcare.org/aging

12. ADRC Update • Recent activity: engage disability community as full partner, complete enhancements to the Call Center and Network of Care web sites and implement last three Work plan activities: • Joint public education and trainings; • Outreach to underserved/underutilizing populations; and • Raise community visibility of the ADRC through media coverage • See new LTC Options Counselor on NOC!

13. LTC Options Counselor • Target audience: consumers, caregivers, “baby boomers” • Goal: get people to think about planning for future needs • Product: web-based, user-friendly guide • Content: categories with links to nationally vetted sites for planning and info • User: may store sites/info in My Folder • Go to: www.sandiego.networkofcare.org/aging, click on “LTC Options Counselor” button on left • Provide feedback for continuous quality improvement

14. Physician Strategy-Planning Phase • Fee-for-service initiative to improve chronic care management across health and social services • Funding: $142,000 (planning) CA Endowment • Partner w/physicians vested in chronic care • Develop interest & incentive for HCBC • 50 physicians engaged in initiative at varying levels • Compiled list of barriers to improving chronic care in primary practices • LTCIP CBOs engaged in problem-solving discussions w/docs & office staff

15. Physician Strategy Update • Implementation Plan for continued funding • Community Care Training/Team-Building (“TEAM SAN DIEGO”) • Chronic Care Management • Understanding aged and disabled populations and needs • Collaboration techniques across health and social service providers • Finding resources for community-based services, patient education material, communication with other providers, etc.

16. Issues for MDs: broad overview • Desire to meet elderly and disabled person’s needs but frustrated • Need help with overlay of today’s environment on a per patient basis • Need for others to: • coordinate transportation to appointments • insure patient can/does follow treatment plan • arrange for/provide needed community services (meals, in-home care, coordination)

17. Issues (continued) • No reimbursement for geriatric/disability assessment across domains • Little reimbursement for MD “extender” staff • No reimbursement for mobile doc mileage/time • Little assistance with translation/diversity needs (what there is may be misdirected) • Little time or reimbursement for chronic care management support

18. Issues (continued) • Problems in patient transitions (e.g. hospital to home) • Inappropriate use of ERs by elderly • No coordination of Medicare and Medi-Cal benefits and services • No measure of long-term outcomes only immediate costs, which is short-sighted • Too many requirements to be able to do everything the doc is supposed to do

19. TEAM SAN DIEGO Objectives • Convene Advisory Committee to describe, support and assist in curriculum development • Develop cross-continuum team care protocol to guide the practical application of team skills in care management • Refine and finalize 8 hour online program and the six-hour classroom curriculum

20. Objectives (continued) • Conduct on-going formative evaluation to assess the impact of the program at three different levels: A. physicians and their staff, B. community-based social service providers, and C. patients (at conclusion of the training sessions and every three (3) months post training during the grant).

21. Objectives (continued) • Make necessary web enhancements based on CQI process including feedback from providers, patients, Advisory Group • Provide for local replicability both locally and nationally, upon successful documentation of positive outcomes.

22. Outcomes • Development of curriculum that encourages primary care providers to practice team care strategies on behalf of patients needing both medical and social supports • Delivery of Team San Diego “business case” to at least 100 physicians. Delivery of TEAM SAN DIEGO 14 hour training to 200 physicians, office staff, and community providers • At least 80% of trainees report improved coordination across providers and settings three months post training. • At least 50% of participating chronic care patients report improved care; know how to better manage care for themselves • Disseminate findings and expand application of team care in San Diego

23. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

24. P P P P P P A A A A A A D D D D D D S S S S S S S S S S S S D D D D D D A A A A A A P P P P P P A A A A A A P P P P P P S S S S S S D D D D D D P P P P P P A A A A A A D D D D D D S S S S S S Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population Community Resources and Policy Organiz-ation of health care Clinical Information Systems Self- Manage- ment Support Delivery System Design Decision Support Develop Strategies for Each Component of the CCM

25. For more information: • Log onto website for background & info: www.sdltcip.org • Call or e-mail: • evalyn.greb@sdcounty.ca.gov, 858-495-5428 or • sara.barnett@sdcounty.ca.gov, 858-694-3252