Long Term Care Integration Project Physician Strategy Reception: Moving Forward May 9, 2006

Long Term Care Integration ProjectLong Term Care Integration Project

Physician Strategy Reception: Physician Strategy Reception: Moving ForwardMoving Forward

May 9, 2006May 9, 2006

Medicare/Medicaid Integration Program Medicare/Medicaid Integration Program ExperiencesExperiences

Robert Wood Johnson FoundationRobert Wood Johnson Foundation

15 Participating States: CO, FL, MN, NY, OR, TX, WA, 15 Participating States: CO, FL, MN, NY, OR, TX, WA, WI, VA, CT, MA, ME, NH, RI, VTWI, VA, CT, MA, ME, NH, RI, VT

For Background and Technical Assistance Documents For Background and Technical Assistance Documents see:see:

Chpre.gmu.edu (Medicare/Medicaid Integration Program)Chpre.gmu.edu (Medicare/Medicaid Integration Program)

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

BackgroundBackground

LTC Integrated care “vision”LTC Integrated care “vision” Healthy San Diego as service delivery Healthy San Diego as service delivery

model model County Medical SocietyCounty Medical Society Board of SupervisorsBoard of Supervisors California EndowmentCalifornia Endowment Issue identificationIssue identification Draft proposal for next stepsDraft proposal for next steps

Physician StrategyPhysician Strategy

Fee-for-service initiative to Fee-for-service initiative to improve chronic improve chronic care managementcare management

Partner w/physicians vested in chronic carePartner w/physicians vested in chronic care Identify interest / incentives for support of Identify interest / incentives for support of

home and community based services (HCBS)home and community based services (HCBS) On-going meetings with physicians On-going meetings with physicians Develop Implementation planDevelop Implementation plan Continuous Quality ImprovementContinuous Quality Improvement

Issues for MDs: broad overviewIssues for MDs: broad overview

Desire to meet elderly and disabled person’s Desire to meet elderly and disabled person’s needs but frustrated needs but frustrated

Need help with overlay of today’s Need help with overlay of today’s environment on a per patient basisenvironment on a per patient basis

Need for others to:Need for others to:– coordinate transportation to appointmentscoordinate transportation to appointments– insure patient can/does follow treatment planinsure patient can/does follow treatment plan– arrange for/provide needed community arrange for/provide needed community

services (meals, in-home care, coordination)services (meals, in-home care, coordination)

Issues (continued)Issues (continued)

No reimbursement for geriatric/disability No reimbursement for geriatric/disability assessment across domainsassessment across domains

Little reimbursement for MD “extender” staffLittle reimbursement for MD “extender” staff No reimbursement for mobile doc No reimbursement for mobile doc

mileage/timemileage/time Little assistance with translation/diversity Little assistance with translation/diversity

needs (what there is may be misdirected)needs (what there is may be misdirected) Little time or reimbursement for chronic care Little time or reimbursement for chronic care

management supportmanagement support

Issues (continued)Issues (continued)

Problems in patient transitions (e.g. hospital Problems in patient transitions (e.g. hospital to home)to home)

Inappropriate use of ERs by elderlyInappropriate use of ERs by elderly No coordination of Medicare and Medi-Cal No coordination of Medicare and Medi-Cal

benefits and servicesbenefits and services No measure of long-term outcomes only No measure of long-term outcomes only

immediate costs, which is short-sightedimmediate costs, which is short-sighted Too many requirements to be able to do Too many requirements to be able to do

everything the doc is supposed to doeverything the doc is supposed to do

Practice Could Be Improved By… Practice Could Be Improved By…

Single source for connecting the complex patient Single source for connecting the complex patient to all needed/appropriate services, w/feedbackto all needed/appropriate services, w/feedback

““Consortium” of providers excelling in care for Consortium” of providers excelling in care for homebound elderly/disabledhomebound elderly/disabled

More affordable, available in-home care (nursing, More affordable, available in-home care (nursing, social work, therapies, safety)social work, therapies, safety)

Better/new IT supportsBetter/new IT supports Reimbursement based on time spent supporting Reimbursement based on time spent supporting

individual needs of patientindividual needs of patient Better trained office staff with more resourcesBetter trained office staff with more resources

Key Medicare/Medicaid Integration Program Key Medicare/Medicaid Integration Program Building Block: Primary Care TeamworkBuilding Block: Primary Care Teamwork

Focus on holistic approach encompassing Focus on holistic approach encompassing health and welfare (e.g., psychosocial, health and welfare (e.g., psychosocial, economic, environmental, social supports)economic, environmental, social supports) Monitor ongoing health status for early Monitor ongoing health status for early detection of problemsdetection of problems Emphasize health education and preventionEmphasize health education and prevention Support chronic care self management Support chronic care self management Increase opportunities for communicationIncrease opportunities for communication

Draft Elements of Implementation Draft Elements of Implementation ProposalProposal

Resources to build a local social network of Resources to build a local social network of chronic care innovators across sectors, chronic care innovators across sectors, setting, and funding by:setting, and funding by:– Community development of “team dynamic” Community development of “team dynamic”

through joint provider educationthrough joint provider education– Enhancement of available IT communication Enhancement of available IT communication

supports for docs, office staff, ancillary and supports for docs, office staff, ancillary and community providers, consumers, caregiverscommunity providers, consumers, caregivers

Proposal (continued)Proposal (continued)

– Enhancement of IT links to information and referral Enhancement of IT links to information and referral sources and state-of-the-art decision support tools, sources and state-of-the-art decision support tools, patient education info, etc.patient education info, etc.

– Work with the UCSD Geriatric Education Center to:Work with the UCSD Geriatric Education Center to: influence geriatric traininginfluence geriatric training improve coordination between disciplinesimprove coordination between disciplines Promote national policy improvementsPromote national policy improvements

– Listen to doctors and other providers to develop Listen to doctors and other providers to develop additional policy improvements within LTCIPadditional policy improvements within LTCIP

Draft Implementation Plan Draft Implementation Plan Feedback: the GoodFeedback: the Good

Engages, educates, builds trust among Engages, educates, builds trust among providers across sectors w/common goalsproviders across sectors w/common goals

Good approach, proven (UCLA & Alz’s)Good approach, proven (UCLA & Alz’s) Recognizes needs/burdens of MDsRecognizes needs/burdens of MDs Builds some needed bridgesBuilds some needed bridges

……the “Bad”the “Bad”

When do docs have time for this?When do docs have time for this? Who will pay docs to do this?Who will pay docs to do this? Is this a “Pollyanna” idea?Is this a “Pollyanna” idea? Can existing IT structures be enhanced or Can existing IT structures be enhanced or

are new/different ones neededare new/different ones needed

Proposal Suggestions To-DateProposal Suggestions To-Date

Include pharmacists in provider team as Include pharmacists in provider team as most aged & disabled are involved w/onemost aged & disabled are involved w/one

Add training on risk avoidance: falls, diet, Add training on risk avoidance: falls, diet, meds, onset of illness & physical changes meds, onset of illness & physical changes report to MDreport to MD

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Community Resources and Policy

Self-Manage-ment Support

Delivery System Design

Clinical Information

Systems

Develop Strategies for Each Component of the CCM

Overall Aim: Implement the CCM for a specific Dual Eligible/Chronic Care Population

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Organiz-ation of health care

Decision Support

CMS Demos To Test Provider-CMS Demos To Test Provider-Based FFS Care ManagementBased FFS Care Management

Support primary/specialist collaborationSupport primary/specialist collaboration

Enhance clinical information communicationEnhance clinical information communication

Increase adherence to evidence-based careIncrease adherence to evidence-based care

Reduce unnecessary hospital and ER useReduce unnecessary hospital and ER use

Avoid costly and debilitating complicationsAvoid costly and debilitating complications

Cultural/Diversity IssuesCultural/Diversity Issues

Rural: access to care, in-home care, transportationRural: access to care, in-home care, transportation ADA accommodations for exam and treatment and ADA accommodations for exam and treatment and

physical accessphysical access Language/culture: Language/culture:

– Need more culturally diverse professionalsNeed more culturally diverse professionals– MDs and translation assistance: availability, cost issueMDs and translation assistance: availability, cost issue– Can extender staff be competent & responsible in this Can extender staff be competent & responsible in this

area?area?