Community Based Care Management Demonstration Project May 22 nd , 2008 Presenters:

1. Community Based Care Management Demonstration Project May 22nd, 2008 Presenters: Geoff Green, Deputy Commissioner Deborah Nichols, Director Schaller Anderson in Maine Denise Levis Hewson, Consultant

2. Demonstration Project is Important Because We Can: • Create a model that can be replicated statewide • Build the capacity at the community level that is needed to sustain a care management program • Meet the legislative mandate that provided a short time line for development and implementation of project

3. Contracting with Schaller Anderson to do the following: • To create the pilot model in three different provider sites (FQHC, PHO, and Physician Practice) • To develop selection criteria and choose the three pilots • To contract and pay the pilot sites for community based targeted care management • To administer the pilot program during the demonstration period

4. Purpose of this Meeting: • To provide an overview of the project: • Project Assumptions • Primary Goals • Participation Requirements • Quality and Performance Metrics • Time Line • To take a brief look at the North Carolina model • Questions and answer session at the end of the presentation

5. Community Care Plan of North Carolina -- Background • NC is mainly a rural state and not well suited for traditional managed care • NC is dominated by small practices and loosely organized medical systems • The county system remains very strong • Since the early 1990s, NC has had in place across the state, a medical home program for Medicaid recipients (PCCM – Carolina Access) • NC Medicaid pays 95% of Medicare FFS

6. Community Care Plan of North Carolina • Built upon a statewide PCCM program: • Medical Homes • Population Management Approach • Quality Improvement Initiatives – Performance Metrics • Targeted Care Management • Focuses on improved quality, utilization and cost effectiveness of chronic illness care • 14 networks with more than 3500 physicians and over 800,000 enrollees (taken 10 years to get statewide)

7. Community Care Plan of North Carolina • Key Attributes of the Medical Home: • Provide 24 hour access • Provide or arrange for hospitalizations and specialty care • Coordinate and facilitate care for patients • Collaborate with other community providers • Participate in disease management / prevention / quality initiatives • Serve as single access point for patients • Receives $2.50 PMPM from the State to manage population

8. Community Care Plan of North Carolina • Community Care Networks: • Non-profit organizations • Includes safety net providers • Steering and medical management committees • Receives $3.00 PMPM from the State to hire care managers and implement quality improvement and disease management initiatives • PCP also gets $2.50 PMPM to serve as medical home and to participate in the disease / care management and quality improvement initiatives • Must partner with health department, department of social services and local hospital (s)

9. Community Care Plan of North Carolina • Lessons Learned • Started small and piloted in 9 networks with 100,000 enrollees • Can’t do it alone – must partner • Community ownership is important • Must develop systems that change behavior • Change takes time and reinforcement • Need to be able to measure change • Comprised of safety net providers • Can be a win-win-win – for patients, providers and the State

10. Care Management Demonstration Project Assumptions • Building upon Maine’s PCCM program – the State is paying the “medical homes” $2.50 PMPM • Recognizing the community based infrastructure needed to support patient centered medical homes for the chronically ill • Targeting “high risk” patients will both improve care and contain the costs of care • Incrementally increasing the FFS payment rate to primary care providers • Committing to build project upon in-state physicians, hospitals and ancillary providers

11. Patient Centered Medical Home Components • Provides “continuous healing relationship” • 24 hour access • Use of care team • Evidence-based treatment for chronic conditions • Support for patient self-management • Systematic follow-up and planned encounters • Intensive management for high risk patients and for those not meeting goals

12. Patient Centered Medical Homes Components (cont.) • Coordination across settings and professionals • Patient tracking and alerts • Care management • Electronic tools, such as: EHRs, registries, etc. • Clinical performance reporting and physician feedback

13. Care Management Demonstration Primary Goals: • Transfer the care management of MaineCare members to community based practices • Create a care management model that can be replicated in urban and rural areas • Improve care while controlling costs • Fully develop the medical home model • Develop the systems needed to support chronic illness care • Identify and stratify the population that will best respond to care mgt. interventions

14. Care Management Demonstration Sites • There will be three pilots: 1) FQHC; 2) PHO and 3) physician practice • Each pilot will target, at a minimum, 300 high risk MaineCare members with a maximum of 50 high risk patients per physician • Pilots will need to meet the participation requirements

15. Care Management Demonstration Quality and Performance Metrics • Collect specified HEDIS measures • Participate in quality reporting program (e.g. pathways, bridges to excellence) • Pharmacy review • Number of enrollees on 10 or more drugs • Percent on generic prescriptions • Increase in medication adherence

16. Care Management Demonstration Quality and Performance Metrics • Care Management/Coordination • Number of adult members with completed PHQ-9 • Number of members with completed HRA • Number of members with completed SF-8 • Improvement in PHQ-9 scores • Improvement in SF-8 scores • Increase in self management of chronic illnesses • Number of members with a care plan in place • Cost Metrics • Average PMPM costs • Total costs

17. Care Management Demonstration Quality and Performance Metrics • Utilization management • Emergency department rates per 1000 • Hospitalization rates per 1000 • Avoidable hospitalization rates per 1000 • Readmission rates per 1000 • Average length of stay • Primary Care Provider • Increase in primary care visits to medical home • Provider satisfaction rate in coordination of care • Number of members with provider consent on care plan

18. Care Management Demonstration Sites Selection Process • Complete Application Process – must demonstrate ability to meet minimum requirements, such as: • 24 hour access • Large enough enrollment and physicians to yield 300 high risk members • Ability to report performance metrics • Processes to integrate behavioral health • Experience and commitment in quality improvement and care and disease management • Willingness to create patient-centered care plans and perform standardized health assessments and screenings • Reconcile care management members on at least a monthly basis, e.g. new members and members no longer eligible • Stratify members by levels of risk and implement outreach appropriate to risk level

19. Care Management Demonstration Sites Selection Process • Must demonstrate ability to meet minimum requirements, continued: • Proactively reach out to targeted members engaging them in their healthcare and performing health risk assessments (HRA), PHQ-9 and SF-8 • Develop a process to receive referrals for high-risk members not in the targeted group but eligible for care management • Develop a process to receive referral for members being discharged from an inpatient setting and following-up to ensure members are incorporated back into the practice and the community • Targeted education to meet members specific needs • Actively use SAMAI web-site tools • Identify a physician champion for the project • Implement disease management initiatives • Assist with social, mental, economic and physical referrals • Coordination of services with other health care providers • Conduct home visits, as needed

20. CareManagement Demonstration Sites Selection Process • Complete sign in sheet and indicate interest to obtain an application form • Expert review panel to review applications • Panel will choose one site only for each provider group for this demonstration

21. Schaller Anderson Responsibilities for Demonstration • Assume full responsibility for the development and implementation of the pilot • Develop a care management project work group to monitor the project, share data and develop new disease and care management initiatives • Utilize the “Predictive Pathways” risk stratification methodology to identify high risk enrollees for each site • Provide each pilot site with a list of high risk patients and their utilization and cost data on a quarterly basis

22. Schaller Anderson Responsibilities for Demonstration • In concert with work group and the State, identify the quality and cost metrics to use in monitoring and evaluating the project • Educate sites on performance metrics • Create quarterly reports for each site that tracks their impact on the performance measures • Provide regular reports on the progress of the care management demonstration project • Conduct a patient and provider satisfaction survey • Be available to the projects sites for consultation, support and technical assistance

23. Summary of Key Dates • May 23, 2008 Application Released • June 6, 2008 Written Question Due • June 11, 2008 Responses to Questions • June 18, 2008 Applications Due • June 26, 2008 Award Three Contracts • July 1, 2008 Project Start Date

24. Care Management Demonstration Contact Information Deborah Nichols, Executive Director Schaller Anderson Medical Administrators 207 Larrabee Road, Suite 6 Westbrook, Maine 04092 Telephone: 207-464-0350 Email: deborah.nichols@schalleranderson.com