Health Home Implementation Update

1. Health Home Implementation Update Session 6 October 10, 2012

2. Agenda • Status of Health Home Implementation • Payment updates • Projected Health Home Assignment • Overview of Datamart Portal • Role of LGU and BHOs as Health Home partners • Interim Referral Guidance

3. PHASE 1 SNAPSHOT • 13 Health Homes designated, HHs, MCPs and converting CM programs may bill for Health Home services. • DOH, HH and MCPs developing operational policies and procedures and improving the transmission of Health Home Patient Tracking file information between NYS DOH and Health Homes and MCPs through the DOH OHIP Portal. • Bronx: BAHN, HHC,VNS of NY Home Care, Bronx Lebanon Hospital Ctr. • Brooklyn: Maimonides, Community Health Care Network, ICL, HHC • Nassau: NS-LIJ, FEGS • Schenectady : VNS of Schenectady and Saratoga • Northern Region: Adirondack Health Institute, Inc., Glens Falls Hospital

4. PHASE 2 SNAPSHOT • 21 Health Homes designated, HHs are in the process of submitting updated network partner lists, entering into Data Exchange Application Agreements (DEAA) with DOH and executing contracts with MCPs. • DOH in discussions with CMS re: SPA approval, HH services cannot be billed until SPA is approved and rates are loaded • Monroe : Anthony L. Jordan , Huther Doyle • Erie : Alcohol & Drug Dependency Services, Inc., Mental Health Services Erie County -SE Corp V, Urban Family Practice, • Hudson Valley : Hudson River HealthCare, Inc., Open Door Family Medical Ctr. Inc., Institute for Family Health • Suffolk: FEGS,, Inc, NS-LIJ, Hudson River HealthCare • Staten Island : Jewish Board of Family & Children’s Services (JBFCS) • Queens : Community Healthcare Network, HHC, NS-LIJ with PSCH, JBFCS • Manhattan: Heritage Health & Housing Inc., Presbyterian, HHC, St. Luke’s-Roosevelt Hospital Center, VNS of NY, and JBFCS

5. PHASE 3 SNAPSHOT • 17 HH designated, DOH is in the final stages of designating Phase 3 HHs (pending for Albany, Otsego, Schoharie, Delaware and Chenango counties). • Designated Phase 3 HHs are working on addressing any contingencies identified in the review of their applications ,entering into DEAAs and MCP contracts and formalizing network partnerships. • DOH in discussions with CMS re: SPA approval, HH services cannot be billed until SPA is approved and rates are loaded . • Northern Region : Hudson River HealthCare, Inc., St. Mary’s Healthcare, Samaritan Hospital, Adirondack Health Institute, Glens Falls Hospital, Visiting Nurse Service of Schenectady & Saratoga Counties, • Central Region: Thomas R. Mitchell, Onondaga Care Management Services, Inc., Upstate Cerebral Palsy, Huther Doyle ,North Country Children’s Clinic, St. Joseph’s Hospital Health Center, Catholic Charities of Broome County, United Health Services Hospitals • Western Region: Mental Health Services Erie County-Southeast Corp V, Niagara Falls Memorial Medical Center, Chautauqua County Dept. of Mental Hygiene

6. Initial Health Home Acuity Scores(those in place for payment prior to Oct 1) • The base patient acuity factors are weighted averages based on total claim costs associated with CRGs for a Health Home eligible population for a given time period. • Initial Phase 1 base acuity scores were adjusted upward for HIV, MHSA and Single SMI illnesses as well as severity level. • These adjusted acuity scores for Phase 1 HH eligible individuals have been provided to Phase 1 Health Homes and Managed Care Plans.

7. Updated Health Home Acuity Scores(for dates of service after Oct 1) • In addition to adjusting the acuity scores for Severity and MHSA/HIV/Single SMI conditions, new weights include additional upward adjustments for: • Individuals that are in the Pairs Chronic and Triples Chronic populations that also have serious mental illness • A risk based add-on from the predictive model (drives dollars to members at higher risk for using more inpatient services) • The new acuity scores are effective October 1, 2012 and will be made available to health homes and plans via the OHIP HCS Portal.

8. Revised Payment Rates and Method • Effective October 1, 2012, Health Home payments will be based on the new acuity scores and will be member specific. • The new acuity scores or “member specific weights” will be loaded to eMedNY within the next week . • If an individual does not have an acuity score at the time a claim is submitted, the claim will go into pend status for 30 days. A statewide average acuity score (from the HH assigned population) will be provided to eMedNY so that the claim will pay.

9. Health Home Rate Calculation for Claims with Dates of Service on/after 10-1-12 • Member Specific Payment Calculation: member specific acuity x applicable HH base rate • Example: 8.2564 x $23.27 = $192.13 • The payment will be automatically calculated when the claim is submitted to eMedNYby the claims payment system.

10. Payment Comparisons – Pairs Chronic and Triple Chronic Populations

12. Additional Phase 1 Health Home Assignments • Additional Phase 1 assignments will include Health Home eligible individuals with a Composite Score > 125 and individuals with a Predictive Model Risk of > 30% • Additional assignments anticipated to be available late fall of 2012 via the OHIP HCS Portal instead of manually.

13. Phase 2 and Phase 3 Health Home Assignments • Health Home assignment files will be available once DEAAs and Portal Functionality is complete. • Assignments will be available via the OHIP HCS Portal • Each Health Home and Managed Care Plan should have at least one HCS contact to download assignment files and upload patient tracking files. Test files should be sent now.

14. Projected Assignments by Phase (based on July 2010/July 2011 HH Eligible Population)

15. Projected Assignments by County – Phase 1(may include a subset of previously assigned Phase 1 members)

16. Projected Assignments by County – Phase 2

17. Projected Assignments by County – Phase 3

18. Projected Assignments by County – Phase 3 (cont’d)

19. OHIP Datamart Portal • Currently available to Health Homes and Managed Care Plans with Health Commerce System Access. • Current Capabilities • Tracking file submission • Recipient look-up • find out member’s HH eligibility, Medicaid eligibility, HH enrollment, and assigned member’s last 5 claims • Enrollment record download (“data dump”) • Creates a file containing all records that a provider has successfully submitted to the portal • Upcoming Capabilities • Assignment file download • Member acuity score file download • Member claim detail Report

20. CRITICAL PARTNERSHIPS: LDSS and LGU’s • Local District Social Services offices (LDSS) and local government units (LGUs) can be a valuable source of information to help outreach to and manage care for assigned members and a referral source for new members. • HH can exchange data with an LDSS or LGU by completing a DEAA subcontractor packet. The LDSS or LGU should determine which staff members need to access HH data (in addition to Medicaid staff who are automatically permitted access ) These staff members should be listed on the DEAA, and access to HH member data would be approved only for these individuals.

21. CRITICAL PARTNERSHIPS: BHOs • The State has entered into contracts with five regional Behavioral Health Organizations (BHOs). The BHOs are monitoring FFS Medicaid admissions for inpatient psychiatric care and detox and reviewing discharge planning. • HHs can execute a Confidentiality Agreement with their regional BHO and arrange to receive alerts if a member is admitted for these services. The HH and BHO can work together on discharge planning and the BHO can also insure the Health Home is part of the discharge planning process.

22. HEALTH HOME REFERRALS • Potential members may be referred for Health Home services • Members do not have to be on DOH lists or be approved by DOH in order to be accepted for Health Home referral. HHs and MCPs are responsible for determining whether the individual presumptively meets criteria for referral. • A Health Home and MCP work group is in the process of developing “rule-in, rule-out” criteria for referrals. Interim guidance has been developed. • This process will be used to prioritize referrals in the initial phases of Health Home implementation (to focus initial Health Home resources to our neediest members). This process will be revisited when Health Homes are more fully implemented. • There are 3 steps to making a Health Home referral:

23. HEALTH HOME REFERRALS-INTERIM GUIDANCE STEP 1- ASSESS ELIGIBLITY: Must meet eligibility for Health Home Services as described in the New York State Health Home State Plan Amendment (claims data should be used whenever available to verify medical and psychiatric diagnoses) • Two chronic conditions (e.g., mental health condition, substance use disorder, asthma, diabetes, heart disease, BMI over 25, or other chronic conditions, OR • One qualifying chronic condition (HIV/AIDS) and the risk of developing another, OR • One serious mental illness

24. HEALTH HOME REFERRALS-INTERIM GUIDANCE STEP 2-ASSESS APPROPRIATENESS FOR HEALTH HOME: Has significant behavioral, medical or social risk factors which can be modified/ameliorated through care management including any of the following: • Probable clinical risk for adverse event, e.g., death, disability, inpatient or nursing home admission • Lack of or inadequate social/family/housing support • Lack of or inadequate connectivity with healthcare system • Non-adherence to treatments or medication(s) or difficulty managing medications • Recent release from incarceration or psychiatric hospitalization • Deficits in activities of daily living such as dressing, eating, etc • Learning or cognition issues

25. HEALTH HOME REFERRALS-INTERIM GUIDANCE STEP 3 -INITIATE REFERRAL: If member meets criteria described in Steps 1-2, the referral can be made on the basis of this presumptive assessment. • Referrals for FFS members are made to the lead HH, referrals for plan members can directly to the MCP or to the lead HH to make the MCP connection. • HHs and plans have access to assignment information in the HCS portal and should check an individual’s assignment status prior to making a referral. • If the individual is already assigned to a Health Home, that Health Home should be contacted to discuss the appropriate course of action. (Additional factors which will quantify criteria in Step 2 are under development by the clinical workgroup-see next slide)

26. HEALTH HOME REFERRALS-INTERIM GUIDANCE Developing Step (coming soon) - QUANTIFY RISK/ACUITY: Has a history of poor connectivity to care, including but not limited to: • No primary care practitioner (PCP) • No connection to specialty doctor or other practitioner • Poor compliance (does not keep appointments, etc) • Inappropriate ED use • Repeated recent hospitalization for preventable conditions either medical or psychiatric • Recent release from incarceration • Cannot be effectively treated in an appropriately resourced patient centered medical home • Homelessness

27. HEALTH HOME REFERRALS-INTERIM GUIDANCE NOTE • If a comprehensive assessment subsequently reveals that the individual does not meet Health Home services criteria, the individual must be transitioned to an appropriate level of care, such as a Patient Centered Medical Home (PCMH). • Referral process for converting TCM programs may differ, e.g., OMH TCM programs and services must be made in consultation with the LGU Single Point of Access (SPOA). • Detailed instructions on how to use the Health Home Member Tracking System to make a referral can be found in the Health Home Member Tracking System specifications document.

28. Resources • Member Tracking System Specifications Document: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/2012-06-26_draft_hh_patient_tracking_system.pdf • Document explaining Tracking System version updates: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/docs/summary_updates_hh_patient_tracking_system.pdf • April Medicaid Update Special Edition (watch for an article in the October Edition): • Health Home Website: http://www.health.ny.gov/health_care/medicaid/program/update/2012/april12muspec.pdfhttp://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/ • Member Assignment, Tracking System, Billing and Rates section of Health Home website: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/rate_information.htm

29. Current Outstanding Issues • Discussion with CMS re: SPAs • Final recommendations re: referrals from Plans and Health Homes clinical workgroup • Working towards assigning children and duals to Health Homes

30. Questions? Questions can also be submitted to the Health Home mailbox (hh2011@health.state.ny.us) with the subject line “Questions Health Home Webinar #6”