Financing Strategies for Care Coordination within the Medical Home

1. Financing Strategies for Care Coordination within the Medical Home Linda Barnhart Public Health Nursing Consultant, CSHCN Program, DOH Pat Shaw CSHCN Coordinator, Clark County November 2, 2006

2. Goal of presentation • Understand where financing care coordination fits within Medical Home Strategic Plan • Understand the goal of the care coordination workgroup • Become familiar with the activities of the care coordination workgroup

3. Medical Home Strategic Plan Financing Goal GOAL: Financing for medical homes is adequate to meet the care coordination needs of children with special needs

4. Strategies for Medical Home Financing Goal • Convene a group of stakeholders to develop an effective strategy for care coordination reimbursement • Pilot reimbursement strategies developed by stakeholder group • Use findings from pilots to implement system changes

5. Getting started:You don’t have to see the whole staircase, just take the first step.Martin Luther King

6. Goal of Care Coordination Workgroup Define an effective financing strategy for care coordination throughout the state and make recommendations • Within the medical home model • For children and youth with special health care needs in Washington State

7. Medicaid DOH CSHCN Family Voices WA Chapter AAP Mental Health Division OSPI Local CSHCN Coordinator Infant Toddler Early Intervention Program Center for Children with Special Needs (CHRMC) Regence Group Health Kids Get Care Workgroup Members

8. So far… • 5 Conference Calls • Work plan developed • Clarification of purpose and roles • Target population identified • Information gathering, in state and out of state

9. Target population • Children with special health care needs • have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and • who also require health and related services of a type or amount beyond that required by children generally

10. Workgroup Has Agreed: • Care coordination (CC) should occur within the Medical Home • CC should communicate with other CC and be one “point of contact” • CC needs to have training and/or credentialing • QA process should be in place • We need more information on current financing, what’s working, what are barriers

11. Discovering the current CC landscape • Questionnaires sent to: • Health Plans • State Agencies • Local Agencies • Pediatrician • 11 Questionnaires returned

12. How does your agency support care coordination? How do you finance care coordination? What is working well for CC in your agency? What are your challenges or barriers? What are your strategies? Questions

13. Support of CC • Providing funds for Care Coordinators or Case Managers • Providing orientation and mentoring to new Care Coordinators • Providing methods of identification of children with special health care needs (e.g. Title V, pharmacy/claims data, referrals, practice database)

14. Financing of CC • Funded through federal, state, or local general fund dollars • Funded through premiums charged to purchasers • Funding started as grant but now supported internally using cost savings and expanding position

15. What’s working • Someone is assigned the role of Care Coordinator (CC) or Case Manager • CC connects children to a medical home • “What’s working” varies because CC varies, e.g. ICM, CC in MH clinic, local level, health plans, developmental of care plans

16. Challenges and Barriers • Need for care coordination greater than available funding • Limited Public Health funding • Many groups with their own funding streams but no one CC “on first” • Limited ability to use funds for more care coordination because of federal requirements • Attempts at billing for CC generally not successful

17. Strategies • Put forward decision packages • Example: HRSA—provide CC to foster children • Example: HRSA—implement pilot project for health navigators • Prioritize care coordination to children with greatest needs (Health plans and local CSHCN programs) • Collect and use outcome data obtained from care coordination grant to support CC (Kids Get Care) • Implement pilot projects • Example: Mental Health Division--using evidence-based practices

18. Do you reimburse for CC? • One Health Plan reimburses for non-physician encounters “if allowed by contract” • No Health Plan respondents reimburse for telephone or email • DSHS/HRSA managed care provides additional payment to contracted health plans for CSHCN; plans may choose to use funding for health plan care coordination function

19. Next Steps… • Continue conference calls • Summarize current information, both from Washington State and other states • Develop recommendations and write report for partners and legislature • Identify strategy for implementing recommendations

20. Questions?