Medicaid ACC Region 1

1. Medicaid ACC Region 1 Eagle, Garfield, & Pitkin Counties Regional POD Meeting, El Jebel September 12, 2012

2. RCCO Region 1 What’s Happening in Your RCCO Region: Information and Updates from Region 1 RCCO, Rocky Mountain Health Plans

3. Vision of the Medicaid ACC Program • Vision of the Medicaid ACC Program • Medicaid Clients in the ACC receive the regular Medicaid benefit package, and choose a Primary Care Medical Provider (PCMP) • The ACC is a central part of Medicaid delivery system reform that changes the incentives and health care delivery processes for providers from one that rewards a high volume of services to one that holds them accountable for health outcomes

4. Design of the Medicaid ACC Program • Design of the Medicaid ACC Program • The design of the program supports a paradigm shift from a volume-driven, FFS model to a coordinated, outcomes-based system that will control costs in a responsible manner. The program is designed not only to improve the Client/family experience and improve access to care, but to establish accountability for cost management and health improvement • 3 primary components of the Program: • Regional Care Collaborative Organizations (RCCOs) – 7 Regions Statewide, 5 Unique RCCOs • Primary Care Medical Providers (PCMPs) • State Data and Analytics Contractor (SDAC)

5. PCMP Criteria for Participation • PCMP Criteria for Participation • In order to enroll as a PCMP in the ACC Program, a provider must be an enrolled • Medicaid provider that meets any one of these criteria:  • Certified by the Department as a provider in the Medicaid and CHP+ Medical Homes for Children program; OR  • A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC) or a clinic or other group practice with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology; OR  • An individual physician, advanced practice nurse or physician assistant with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics, or obstetrics and gynecology • PCMPs sign contracts with the State and the RCCO serving their region

6. PCMP Responsibilities • PCMP Responsibilities • PCMP serves as a Medical Home for Members • Member/Family Centered • Whole Person Oriented • Coordinated • Promotes client self-management • Care provided in a culturally and linguistically sensitive manner • Accessible

7. Region 1 PCMP Network • PCMP Network • The Region 1 PCMP network includes Federally Qualified • Health Centers (FQHCs), Rural Health Centers (RHCs), • private practices, pediatric practices, and family medicine • residency programs, all of which are committed to serving as a • Medical Home for RCCO Members.

8. RCCO Region 1 • SDAC Responsibilities • -Treo Solutions serves as the SDAC • -The SDAC’s responsibilities include: • Data Repository • Data Analytics & Reporting • Web Portal & Access • Accountability & Continuous Improvement

9. RCCO Region 1 • PCMP & RCCO Payment • FFS Reimbursement to PCMPs for Medical Services • Per Member Per Month (PMPM) payments to PCMPs for Medical Home services • PMPM payments to RCCOs for PCMP support and Member care coordination* • Incentive payments • *Children’s Medical Home providers do not receive the PMPM because they are already receiving the enhanced rate

10. Enrollment: Initial Phase • Enrollment: Initial Phase • Member enrollments in the Program commenced in June 2011 • Selection of clients performed by the Department, through the SDAC • Clients selected from two populations: Clients Newly Eligible for Medicaid and Existing Medicaid Clients with a Relationship with a PCMP Participating in the RCCO’s Network & Focus Community • Voluntary / Passive Enrollment – Selected Clients receive an enrollment letter, and can opt out by contacting the enrollment broker, HealthColorado. If client does not contact HealthColorado to opt out, client is passively enrolled • During the Initial Phase, Program enrollment was capped at approx. 60,000 Members statewide; was later increased to 123,000 due to budget action • Approximate ratio of 2/3 Adults: 1/3 Children • During this phase, RCCOs established focus communities within their regions

11. Enrollment: Expansion Phase • Enrollment: Expansion Phase (Current) • Current Statewide Enrollment* : 141,795 • Current Enrollment in Region 1*: 14,641 • At the end of July, the Department issued a Position Statement on Next Steps for Expansion • Initial results of this program are promising; costs, utilization and client experience are trending in the right direction.  • On November 1, 2012, the Department will submit a response to the legislative request for information concerning the ACC, to include initial program results such as utilization and costs. • Next steps for expansion include: • Beginning in October, the Department will remove the limit on the number of children enrolled in the program.  The Department will prioritize the enrollment of children who can be linked to a Primary Care Medical Provider (PCMP). • Beginning in November, the Department will enroll the clients of the Comprehensive Primary Care Initiative (CPCI) practices in the ACC Program. • By Spring of 2013, the Department will begin to enroll clients dually eligible for both Medicaid and Medicare into the ACC Program. *as of July 2012 Roster Report

12. A Regional Approach • A Regional Approach • The design of the ACC Program focuses on regional collaboration with a focus on cost management and health improvement • RCCOs leverage local relationships with and between providers and community-based organizations and build upon existing regional systems of care • By managing Members on a regional basis and focusing on regional outcomes, performance, and costs, the RCCOs and SDAC are well positioned to enhance Members’ abilities to appropriately utilize the health system, offer providers consistent data and analysis to support care delivery, and enhance providers’ efforts to deliver outcomes-based care • Regional approach also promotes the sharing of best practices

13. RCCO Regions

14. RCCO Responsibilities • RCCO Responsibilities • Achieve outcomes • Ensure comprehensive care coordination & a Medical Home level of care for every Member through: • - Network Development/Management • - Provider Support • - Medical Management and Care Coordination • - Accountability/Reporting

15. ACC Program Objectives • As a RCCO, We Focus on Achieving the Following ACC Program Objectives • Expanding access to comprehensive primary care • Providing a focal point of care/Medical Home for all Members including coordinated and integrated access to other services • Ensuring a positive Member and provider experience and promoting Member and provider engagement • Effectively applying statewide data & analytics functionality to support transparent, secure data-sharing and enabling the near-real-time monitoring and measurement of health care costs and outcomes

16. RCCO Region 1 • RCCO Region 1 includes the following 22 counties: • Archuleta • Delta • Dolores • Eagle • Garfield • Grand • Gunnison • Hinsdale • Jackson • La Plata • Larimer • Mesa • Moffat • Montezuma • Montrose • Ouray • Pitkin • Rio Blanco • Routt • San Juan • San Miguel • Summit

17. RCCO Region 1 Focus Communities RCCO 1 Focus Communities

18. RCCO Region 1 Focus Communities • Region 1 Focus Communities • 4 Communities with Highest Number of ACC Enrollees • North Larimer County (Fort Collins) • South Larimer County (Loveland) • Routt and Moffat Counties (Craig & Steamboat Springs) • La Plata and Southwest Counties (Durango)

19. RCCO Region 1 Focus Communities • Region 1 Focus Communities • RMHP is collaborating with a network of community providers who are organizing around a “medical neighborhood” model for care management and care coordination • RMHP and key partners in each community are working to maximize/optimize the providers’ ability to take on complex patients according to methods specific to their community’s unique needs and resources • RMHP has developed Care Coordination Teams in each focus community: • Transdisciplinary teams • Embedded at predictable times in provider offices • Community leadership with PCPs, public health depts., convening organizations and hospital involvement in all cases • The teams are in the community and know the services; they’re already trusted

20. RCCO Region 1 Levels of Care • Level 1 Prevention and Wellness • Level 2 Disease Management • Level 3 Coaching • Level 4 Complex Case Management • Level 5 Transition of Care

21. The “Three T’s” of Care Coordination

22. Effective Care Coordination: by Focus Community • Fort Collins • - Social work, behaviorist and APRN model • - Embedded in practices • Loveland • RN with BH and team back up; embedded in safety net clinic • Steamboat • Behaviorist plus Case worker model with home & hospital visits • Durango • Nurse navigators and Promotoras that focus on separate age groups

23. A Look at Each Focus Community:North Larimer County • In North Larimer County, key partners include representatives from the following organizations: • Primary Care Clinics: Salud Family Health Centers, Fort Collins • Family Medicine Center (PVH residency program) • Associates in Family Medicine • Mental Health Provider: Touchstone Health Partners (formerly Larimer Center for Mental Health) • Community Care Coordination team Project Coordinator: Poudre Valley Health System Foundation • Convening Organization: Health District of Northern Larimer County • These partners are funding a local, centralized care coordination service for the most high cost, high • needs Medicaid ACC members who have a participating PCMP in North Larimer County. • The team works side-by-side with the hospital community care coordinators. Touchstone Health Partners • employs one of the care coordinators to enable the team to refer appropriate RCCO members for • immediate acute behavioral health services, incorporating a behavioral health skill set into the team-based • model for care coordination.

24. A Look at Each Focus Community:South Larimer County • In South Larimer County, key partners include representatives from the following organizations: • Primary Care Clinics: Sunrise Community Health Center, Loveland • Banner Health Family Medicine practices in Loveland and Berthoud • Big Thompson Medical Group Family Medicine practices in Loveland and Berthoud • Mental Health Provider: Touchstone Health Partners (formerly Larimer Center for Mental Health) • Care Coordination Project Coordinator: Northern Colorado Health Alliance (NCHA) • These partners are funding a local, centralized care coordination service for the most high cost, high • needs Medicaid ACC members seeking care in South Larimer County. Touchstone Health Partners works • closely with the NCHA care coordinators to enable the team to refer RCCO members for immediate acute • behavioral health services as appropriate, incorporating a behavioral health skill set into the team-based • model for care coordination. • .

25. A Look at Each Focus Community:Routt & Moffat Counties • In Routt and Moffat Counties, key partners include representatives from the following organizations: • Primary Care Clinics: Yampa Valley Medical Clinic • Steamboat Springs Family Medicine • Steamboat Medical Group • Northwest Colorado VNA Community Health Center • Mental Health Provider: Colorado West Regional Mental Health Center • Care Coordination Project Coordinator: Colorado West Regional Mental Health Center • Project Convening Organization: Northwest Colorado Visiting Nurses Association • These partners are funding a local, centralized care coordination service for the most high cost, high • needs Medicaid ACC members seeking care in Routt and Moffat Counties. • At the current time, the Care Team consists of two (2) full-time positions employed and supervised by • Colorado West Regional Mental Health. The Care Team is working closely together to address care • coordination and behavioral health support to PCP clinics and the ER in Steamboat Springs.

26. A Look at Each Focus Community:La Plata & Southwest Counties • In the Southwest Counties, key partners include representatives from the following organizations: • Primary Care Clinics: Mercy Health Services Clinic • Pediatric Partners of the Southwest • Primary Clinic at Pagosa Springs Medical Center • Mental Health Provider: Axis Health System (formerly Southwest Regional Mental Health Center) • Project Convening Organizations: Southwest Colorado Area Health Education Center • San Juan Basin Health Department (SJBHD) • These partners are funding a local, centralized care coordination service for the most high cost, high • needs Medicaid ACC members seeking care in Southwest Colorado. The SJBHD is housing the care • coordination team, also known as the “RN Navigators.” The staff is comprised of 3 nurses, each • specializing in care for children, adults or elders, respectively. The SJBHD will also utilize an already- • established Promotora, a lay-person that specializes in providing culturally competent access to care for • native Spanish speakers, which is the predominant language other than English spoken in the region.

27. How are Care Coordination TeamsDeveloped? • Criteria for development of a CCT is an adequate volume of Medicaid Members enrolled in the area, along with strong community and provider leadership • This type of model is something a community can grow into in the future

28. Care Coordination Resources for Communities without CCTs • Rocky Mountain Health Plans Case Managers are available to help with RCCO Care Coordination services • Our care management and disease management programs will support providers that need support in managing more complex patients

29. Data Supported Targeting of Care Coordination Efforts • Targeted Care Coordination efforts are supported with data focused on chronic disease load, BH co-morbidities and utilization patterns • Care Coordination Teams and internal RMHP Care Management Team use SDAC data/reports, in conjunction with a Care Management Analysis Tool that we develop using raw claims data and Roster Reports, provided by the State. This tool allows Care Coordinators to identify appropriate Members for services

30. Supporting Members & Providers • RMHP’s role as RCCO is multifold: • Serve as a one-stop shop of information and resources for members, medical providers, and program stakeholders in Region 1 • Work actively with community partners to create patient-centered care coordination systems that listen, reflect, and respond to patient needs and improve the health of Members. • Support the use of data at every point in the care coordination process to help align appropriate health, behavioral and human services with the unique needs of each patient. • Work with each local community to establish the structures, communications, expertise and leadership to create Medical Neighborhoods. • Benefits for Members include: • Coordinated Client Care • RCCO can help Members/families access resources and supports beyond primary medical care

31. Supporting Members & Providers • Oversight Committees • Community Forums • Motivational Interviewing Toolkit; PAM • Linking Members to Providers and Strengthening ties to the Medical Home • Gaps in Care reports • Member postcards • Provider Newsletters

32. “Unconditional Care”* • A true Client story: • “Life changing! Off the chart! Found a perfect program for [Client]; and she helped more than one family member. –> I can not say enough about our care coordinator and the difference she made in our lives. Sarah helped [Client], a 22 year-old disabled person. [Client] spent an entire year after she graduated from high school alone and disconnected, in her bedroom 24/7. Due to the poor health of mom, [Client] [did] not get any chance to get out. When our care coordinator came to help us, after several visits, she helped us find a program called ‘Mindset’. After helping us fill out all the forms, Sarah helped us be accepted into Mindset. [Client] went from spending 24/7 in her bedroom, to attending mindset weekdays from 9-3. The program integrates people with disabilities into their community. They swim, bowl, go to parks, have a garden, cook, and learn life-skills. [Client’s] entire life has changed for the better. It is completely due to our care coordinator, Sarah.” ~mother of client

33. Thank You & More Information • Patrick Gordon, Director of Government Programs & Director of the Colorado Beacon Consortium; patrick.gordon@rmhp.org • Nicole Konkoly, Medicaid ACC Community Coordinator, RCCO Region 1; nicole.konkoly@rmhp.org