San Diego Long Term Care Integration Project

1. San Diego Long Term Care Integration Project Personal Care Services Workgroup October 5, 2005

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. 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

5. Service Delivery Models Fee-For-Service Managed Care Integrated Care • Issues/Features • No care mgmt or service coordination • Traditional payment incentives - the more you do, the more you make • System/Provider driven • Defined benefit list/fee schedule • Lack of QA/QI measures & oversight • Issues/Features • Utilization management • Capitated payment incentives - the less you do, the more you make • PCP/Gatekeeper driven • Defined benefit list • QA/QI driven by cost containment • Issues/Features • Chronic care mgmt & coordination across health & social service continuum • Pooled funding incentives; payment matches risk = right service, at the right time, in the right setting • Consumer driven • From defined benefit list to what indiv. needs/ prefers • Comprehensive QA/CQI built into system

6. LTCIP Strategies • Network of Care (NOC) • Web-based information & communication system to support the 2 service delivery models below • Physician Strategy • Managed Fee-For-Service initiative to improve chronic care management • Healthy San Diego Plus (HSD+) • Integrated service delivery model that provides the full continuum of health and social services

7. Network of Care (NOC) • 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

8. Physician Strategy • Fee-for-service initiative to improve chronic care management • Funding: $142,000 (planning) CA Endowment • Partner w/physicians vested in chronic care • Develop interest/incentive for support of HCBC • ID care management resources • Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports • Falls Prevention initiative

9. Fully Integrated Model • In SD, known as Healthy San Diego Plus (HSD+) • Builds on geographic managed care model for Medi-Cal • Option to mandatory primary & acute enrollment for ABDs • Pooled Medi-Cal (& Medicare for duals) health and supportive service $$ • From defined benefit list to what individual needs/prefers • Care manager and member in “hub”

10. Community Planning Process • From 50 to 700+ key stakeholders over past 6 years: 22,000+ hours • Seeking to improve system of care for consumers and providers • Agreement to use existing providers, assure fair compensation • Planning within state LTCIP authorization (form follows funding)

11. Long Term Care Integration Project Organizational Chart & Decision Tree San Diego County Board of Supervisors & State Office of Long Term Care Jean Shepard,Director County of San Diego, Health & Human Services Agency, (HHSA) • Internet • Facilitates communication • Provides broad public education Pamela B. Smith, Project Director Evalyn Greb, Project Manager Aging & Independence Services Lead County Agency Advisory Group: Goal: Make final decisions and recommendations for inclusion in the plan. Planning Committee: Goal: Guide the LTCIP planning process. Suspended Workgroups pending need for further action/decision-making Health Plan Partners Workgroup Finance/Data Workgroup Options Workgroup MH & SA Workgroup Community Education Workgroup LTCI Strategies: 1) Network of Care 2) Physician Strategy 3) Healthy San Diego Plus Workgroups: Care Management, Provider Network Development, Cultural Responsiveness Explore use of public health education models that promote improved chronic care management for LTCIP Determine the financial feasibility of the proposed LTCIP for San Diego County. Make recommendations to Planning Committee re: inclusion of mental health and substance abuse services in LTCIP. Explore use of the Healthy San Diego model for potential Service delivery system for LTCIP. Governance -Case Management -Info/Technology -Quality Assurance -Scope of Services -Workforce Issues -Developmental Disabilities -Community Network Development www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc/

12. 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

13. 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

14. Legislative Authority • AB 1040 in 1995 (revised in 1998) • State Office of LTC: • provides planning $$ ($873,000 to-date) • provides “Center” resources • provides liaison with other state programs • approves local activity toward LTCI • will assist in procuring federal waivers • (? budget for FY 05-06)

15. Why change? • To align incentives for optimum care across the continuum • To impact quality of life for aged and disabled, especially high cost users • To respond to demographics that require Medicare to respond to chronic care needs • To shift focus to consumer and outcomes • To support consumer desire to “age in place” • To respond to Olmstead Decision

16. Statement of Need • Aging Population • San Diego County to increase significantly • Elderly:14% today; 25-33% by 2030 • From 1990 to 2010, 75+ increases by 81% • 85+/minority elderly: fastest growing segments • 60% of those 65+ will require long term care services at some point • Those who need service can’t find it • Care is fragmented by regulation! • Providers asked to do more w/less • Medi-Cal Redesign proposes expansion to ABDs

17. Statement of Need (cont’d) • Expenditures • LTC recipients represent: 25% of Medicaid population, 70% of Medicaid expenditures • San Diego ABD enrollees/month - 90,000 • 20,000 IHSS consumers • 62% of ABDs are dually eligible (Medi-Medi) • 90% of those 65+ are dually eligible • Projected annual expenditures for Medi-Medi’s • Medi-Cal: $1.2 B (CY 2005) • Medicare: $.5 B (CY 2005) • Only 7% of US population currently has private LTC insurance (narrow population can benefit) • Resources insufficient to meet future demand

18. From Vision to Service Delivery Model… • Explore Healthy San Diego due to: • Access, education, prevention • Advocacy • Cost-effectiveness • Population-based • Existing infrastructure • Stakeholder-designed, BUT

19. HSD Currently Does NOT… • Tailor the program for chronic care or aged and disabled persons • Provide “wraparound” services • Provide chronic care management on a population basis • Receive adequate reimbursement for chronic care • Have much info on “duals”

20. LTCIP Workgroups • NEW: Personal Care Services • Governance • Care Management • Information Technology • Quality Assurance • Scope of Services • Health Plans • Finance/Data

21. LTCIP Workgroups • Developmental Disabilities • Mental Health & Substance Abuse • Community/Provider Network Development • Community & Cultural Responsiveness • Community Education

22. Why should stakeholders get involved? • To influence planning and decisions • To impact delivery of acute & LTC needs of individuals (support+services) • To recommend how to include personal care services into the fully integrated model

23. Current Reality • Medi-Cal Redesign and ALTCI • ABDs to be mandated in Jan. Budget for primary and acute managed care? • IHSS to be included in ALTCI services • OLTC and health plan CMs • Medicare Modernization Act (SNPs) • Mercer Rate-Setting Report • Local recommendations for RFSQ • Provider Network • Care Management • Community & Cultural Responsiveness

24. Other national LTCI programs • PCS provided according to need • Health plan responsible for assessment and authorization of all but medical svcs • Greater # receive in-home care • Hours/individual have not increased • Co. staff still in PCSP, working for health plan (higher pay), or new Co.job

25. Assumptions • Voluntary enrollment beginning July 2007 • Eligible population: up to 95,000 Medi-Cal-only and dually eligible aged, blind and disabled persons, 21yo+ • PCS included as a benefit • One care manager • Single multi-dimensional assessment • One Care Plan

26. LTCIP and Personal Care Services • Eliminate duplicate assessments/plans • Replaces IHSS regs w/quality indicators • CM to assess across all needs and preferences w/consumer on “team” • PCS is one of many plan services available • Monitoring/reassessment more frequent • Helps provide new incentive for health plans: stabilize at-risk individuals with home care, avoid inappropriate ER, hospital, SNF use

27. Personal Care Services Workgroup Goal • To forward a recommendation to the Planning Committee on how to best integrate personal care services into HSD+ in a manner that is consistent with the LTCIP stakeholder vision

28. How to influence planning? • Next Workgroup meeting: Oct. 19, 1:00-3:00, Pt. Loma Nazarene University, 4007 Camino Del Rio South, SD CA 92108 (Mission Valley area) • 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: evalyn.greb@sdcounty.ca.gov, 858-495-5428 or sara.barnett@sdcounty.ca.gov, 858-694-3252