A Promising Collaboration: Managed Care and Independent Living · 2019-10-23 · 2015, and converted to a non-profit managed health plan Care1st was awarded contracts for Medicare

National Association of Area Agencies on Aging

A Promising Collaboration: Managed Care and Independent Living

Part of the Aging and Disability Business Institute Series – a collaboration of n4a and ASA.

Louis Frick, MS, CRC

Executive Director, Access to Independence, San Diego, CA

Pamela M. Mokler, MSG

Vice President of Long Term Services and Supports, Care1st Health Plan, an affiliate of Blue Shield of California, Monterey Park, CA


The “Business Institute”

The mission of the Aging and Disability Business

Institute (Business Institute) is to successfully build and

strengthen partnerships between community-based

organizations (CBOs) and the health care system so older

adults and people with disabilities will have access to

services and supports that will enable them to live with

dignity and independence in their homes and

communities as long as possible.

www.n4a.org/businessinstitute

http://www.n4a.org/businessinstitute


Partners and Funders

Partners:

• National Association of Area Agencies on Aging

• Independent Living Research Utilization/National Center for Aging and Disability

• American Society on Aging

• Partners in Care Foundation

• Elder Services of the Merrimack Valley/Healthy Living Center of Excellence

Funders:

• Administration for Community Living

• The John A. Hartford Foundation

• The SCAN Foundation

• The Gary and Mary West Foundation

• The Colorado Health Foundation

• The Marin Community Foundation

Care1st Health Plan, a non-profit affiliate of Blue Shield of

California Care1st was created in 1994 by three medical groups & a

disproportionate share hospital dedicated to providing health care services to vulnerable populations

Care1st was acquired by Blue Shield of California in October 2015, and converted to a non-profit managed health plan

Care1st was awarded contracts for Medicare and Medi-Cal

Care1st offers 7,000+ provider networks & serves approximately 700,000 members in California, Arizona, and Texas

NCQA Commendable Accreditation. Ranked as a top Medicaid health plan in California by Consumer Reports.


http://www.n4a.org/

http://www.asaging.org/

Health Care System Transformation

We are creating an integrated, seamless system of acute medical, behavioral health and long-term services &

supports that offers an array of individually tailored and culturally competent medical, social, and supportive

services that promote access and consumer choice, dignity, and maximum independence. The system integrates

funding and case management functions throughout the continuum, and include integrated data managed systems

accessible to all providers.

Part of the Aging and Disability Business Institute Series – a

collaboration of n4a and ASA.

Health Care System Transformation (Continued)

• Ultimate goal for all Stakeholders is a health care system that operates effectively and efficiently to ensure that all people get the care they need, at the right time, in the right place, and that invests in helping keep us healthy

• Changing the current system requires a fundamental shift in the way health care & long term services & supports are financed and delivered. As with any paradigm shift, it’s not a quick & easy task!


An Independent Living and Managed Care Collaboration

• Background:

San Diego was preparing for managed care for Medicaid beneficiaries with disabilities

• Goals:

Pilot project with people experiencing homelessness with disabilities in San Diego, CA

• Methods to identify participants

• Assessment and services provided

• Outcomes

• Lessons learned


Background: Preparing for Move to Managed Care – 2012

• 8,057 people with disabilities and seniors who were Medicaid beneficiaries in SD992 – Seniors

243 – Seniors with both Medicare and Medicaid (Duals)

5,783 – People with disabilities

1,039 – People with disabilities with both Medicare and Medicaid (Duals)


High Priority Challenges and Needs of PWD/Seniors

• Homeless or transient

• Mental health and substance use disorder issues, including serious mental illness (SMI)

• High emergency room utilization

• Priority needs: Emergency shelter, transitional or temporary

housing, permanent housing, food and transportation

Long term services and supports (LTSS)/supportive services


PWD and Seniors Pilot Goals

• Test and develop a working model to prepare for dually eligible demonstration

• Test impact of housing placement for homeless PWD and seniors on health care utilization

• Build institutional knowledge and capacity of Care1st by fostering institutional knowledge about PWD and seniors who are homeless


PWD and Senior Pilot Project Time Frame

• 12/2012: Initial meeting with Access to Independence (A2i)

• 2/2013:

Care1st staff hired

Contract with A2i for external case management (ECM)

• 3/2013 – 4/2013: Clinical systems developed, work flow, kickoff meetings,

test cases, web portal

• 5/2013 – 11/2013:

7-month pilot

Post-pilot evaluation


Pilot Participant Selection Criteria

Phase I:

•Current members as of April 2013

Cannot be reached by phone, or

Have “Homeless” in address field AND

293 people identified by 6-month utilization thresholds

• Greater than $10,000 and up total

• Greater than $5,000 Emergency Room


How Pilot Participants Were Found

Phase II

•58% identified during hospital stays

•19% identified during emergency room visits

•16% Identified via total utilization of all services

•7% didn’t meet above criteria - identified via case management activities & providers as at potential risk for placement


PWD and Seniors Pilot Workflow Access to Independence

• STEP ONE: Referral request for services from Care1st

• STEP TWO:

Find/contact member to conduct assessments, obtain consent

• STEP THREE:

First 30 days, complete and upload

Independent Living Plan (ILP)

Pilot Heath Risk Assessment (Pilot HRA)

Care Transition Plan for members in SNFs, rehab, and acute care hospitals


PWD and Seniors Pilot Workflow Access to Independence

• STEP THREE:• Months 2 – 6

Update ILP or

Update Care Transition Plan

Participate in Care1st Care Coordinationmeetings

Monthly reports


PWD and Seniors Pilot Workflow Care1st Case Manager/Social

Worker• Case Management

Member Assessment

• Health Risk Assessment (HRA)

• Individualized Care Plan

Member Case Management

• Problems, Goals, Interventions

• Coordination of medical care with St. Vincent,Federally Qualified Health Center’s (FQHC’s)

• Authorizations for services and transportation, etc.


PWD and Seniors Pilot Workflow Care1st Case Manager/Social

Worker• Social Services

Independent Living Plan (ILP)/Independent Care Plan (ICP) review, coordination with Access to Independence

Weekly case conference with Medical Director and VP Medical Management


Identifying PWD and Senior Pilot Participants

• 66 PWD and seniors identified/recruited/enrolled48 found in hospitals18 found by Access to Independence

• 51 completed the pilot

10 received care through homeless clinic (St. Vincent de Paul’s)

41 received care through primary care providers or Federally Qualified Health Centers (FQHCs)

• 23 of 51 who completed Pilot, continued to be case managed by A2i following Pilot & were still eligible as Care1st member


Housing Placements for Pilot Participants

• 45% of 66 (29 people) were placed in housing

A2i has close ties to housing providers

• Out of 23 still eligible after Pilot, 15 were placed in housing

• 14% received services other than housing

A2i provided: groceries, furniture, rent, environmental adaptations


Hospitalizations and Length-of-StayPre-, During, and Post-Pilot – All

Participants

• Pre-pilot (4 months)Number of hospitalizations: 1Average length of stay: 4.88 days

• Pilot (7 months)Number of hospitalizations: 2.88Average length of Stay: 8.96 days*

• Post-pilot (4 months)Number of hospitalizations: 1.13Average length of stay: 4.43 days

* Increased hospitalizations and lengths of stay during pilot due to increased services following HRA and A2i’s Independent Living Plan (Care Plan)


Hospitalizations and Lengths of Stay for 15 Placed in Housing

Out of 23 still eligible at end of Pilot:

• Pre-pilot (4 months)

Number of hospitalizations: 1.53

Ave. length of stay: 6.67 days

• Pilot (7 months)


Ave. length of Stay: 15.87 days*

• Post-pilot (4 months)


Ave. length of stay: 0.5 days


Readmissions to Hospital for 15 Members Placed in Housing

Out of 23 still eligible at end of Pilot:

• Pre-pilot (4 months)Number of members: 2

Readmissions: 5

• Pilot (7 months)Number of members: 4

Readmissions: 12

• Post-pilot (4 months)Number of members: 1

Readmissions: 1


Emergency Room Visits for 23 who wereCare1st Members at End of Pilot


Number of ER visits: 2.41






Emergency Room Visits Among 15 of 23 Remaining Members who were

Placed in Housing








Reflections and Observations

• Pilot results need further study to look at why utilization increased during pilot; also to study long-term outcomes of individuals participating in Pilot who are still Care1st members

• Benefits derived from housing placement and case management

• Lessons learned about member population and placement

Helped build foundation for dually eligible demonstration

Created a commitment by both Care1st and Access to Independence to continuing the collaboration


Reflections and Observations

• Most important outcomes:

(1) Intervention worked for those placed in housing who remained a Care1st member at end of Pilot; and

(2) Strong partnership between Care1st and A2i, the Independent Living Center in San Diego County.


Example of LTSS Provider/Vendor Contracting Criteria

• Geographic Availability• Cost• Timeliness• Experience• Continuity of Service• Cultural, Ethnic & Language Needs• Qualified Staffing• Member Preference


Questions & Answers:

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Learn more and pre-register here:http://www.asaging.org/series/109/aging-and-disability-business-institute-series

Please join us for future webinars in the Aging and Disability Business Institute

Series

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Documents

A Promising Collaboration: Managed Care and Independent Living · 2019-10-23 · 2015, and converted to a non-profit managed health plan Care1st was awarded contracts for Medicare