LESSONS FROM THE FIELD - advancingstates...LESSONS FROM THE FIELD CREATIVE STRATEGIES FOR INTEGRATING SERVICES AND IMPROVING QUALITY OF CARE FOR ELDERS AND ADULTS WITH DISABILITIES

© 2013 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information

LESSONS FROM THE FIELD CREATIVE STRATEGIES FOR INTEGRATING

SERVICES AND IMPROVING QUALITY OF CARE FOR ELDERS AND ADULTS WITH DISABILITIES

Confidential & Proprietary Information

COMMONWEALTH CARE ALLIANCE

• Not-for-profit, consumer-governed organization

• Prepaid care delivery system for the most complex Medicare and Medicaid beneficiaries

• Uses Medicare/Medicaid risk adjusted premiums to redesign care for seniors enrolled in the Senior Care Options Program (SCO) and younger adults with disabilities enrolled in the One Care Program

• Provides enhanced primary care and care coordination through multidisciplinary clinical teams

• Invests in primary care, behavioral health, geriatric, and long-term services and supports

• Creates savings from reduced hospital and institutional care

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HEALTHY IS HARDER FOR SOME. THAT’S WHY WE’RE HERE.

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CURRENT PROGRAMS

Senior Care Options

• Fully Integrated Dual Eligible Medicare Advantage Special Needs Plan

• Nearly 5,500 elders • 77% nursing home certifiable • Integrated, multidisciplinary primary care teams

developed in collaboration with primary care partner sites

• Utilizes both a delegated network model as well as deploying our own interdisciplinary clinicians

• Excellent outcomes to date

Program for Individuals with Severe Physical and Developmental Disabilities

• Delivered through Commonwealth Community Care, a specialized inter-disciplinary medical practice

• Nearly 700 patients currently in care • Integrated teams of clinicians and support staff

providing home-based primary care and therapy and managing durable medical equipment

• Coordinating existing relationships with specialists • Practice is expanding to 4 new locations in

Massachusetts, caring for over 2,000 individuals with disabilities

One Care Program

starting in October

2013!

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SENIOR CARE OPTIONS

• Began in 2004 as a Demonstration Program in Massachusetts pioneered by CMS and MassHealth for both dual eligible and MassHealth “only” beneficiaries aged 65 and over

• Comprehensive benefit package—all Medicare and MassHealth benefits, including behavioral health, the full array of home and community based services, PLUS

• Melded into a D-SNP program in 2006, currently regulated as a Medicare Advantage plan in that context—Fully Integrated Dual Eligible Special Needs Plan (FIDESNP)

• Integral partnership between SCO Programs and Area Agencies on Aging (or ASAPs in Massachusetts)—SCOs contract with AAAs for the services of geriatric social workers (Geriatric Service Support Coordinators, or GSSCs)

Overview

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SENIOR CARE OPTIONS

• Clinical model of enhanced primary care involves hands on care by our nurse practitioners and nurses who are fully integrated into primary care practices and work hand-in-hand with physicians—well beyond “remote” care management. Critical to the success of the model is the role of home and community based services deployed to sustain enrollees safely in home based settings

– Robust home visiting program by our interdisciplinary clinical teams (including GSSCs) enhances ability to respond to episodic care needs

– Teams responsible for transitions of care and continuity of care across care settings (home to hospital to sub-acute/SNF to home)

– Enhanced ability for physicians to know member’s health status beyond office visits, and to extend the physician’s capacity to provide home based care when needed; effective “hand offs” for care coordination

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Our Model of Care


ONE CARE

• Nationally recognized as CMS/MassHealth’s “duals demonstration”

• Initiative of the Affordable Care Act

• Also referred to as ICO program

• All states invited to participate; Massachusetts is the first

• Eligibility

– People with Medicare and MassHealth Standard – Ages 21 through 64 – Approximately 90,000 people

Overview

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ONE CARE

• Integration of primary care and behavioral health care

• ICOs are entities accountable for delivery and management of care—receive global payment

• Interdisciplinary care teams led by primary care or behavioral health clinician

• Individualized care plans for all members

• Care coordinators for all members

• Benefit package—Medicare and Medicaid benefits PLUS

Massachusetts Design

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A PROVEN TRACK RECORD

• 30 years serving people with disabilities across the lifespan

• Over 6,000 elders and younger adults with disabilities currently in care

– 77% of community-living elders are nursing home certifiable • Meeting and exceeding national quality and cost standards

– Significant reductions in hospitalization admissions and days – Significant reductions in hospital readmissions – Significant reductions in permanent nursing home placements – 7 year cost trend significantly below Medicare trend – CMS Quality Star Rating = 4.5 stars (2013)

Commonwealth Care Alliance

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STRATEGIES: SENIOR CARE OPTIONS


SENIOR CARE OPTIONS

• Referral received for potential enrollment in SCO program

• Determine eligibility

– Dual eligible/MassHealth standard – Financial disparity

• Educate consumer about SCO Program

– Elective enrollment on the first of each month

Enhanced Primary Care

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SENIOR CARE OPTIONS

• Minimum Data Set (MDS) a multi-domain assessment tool performed every 6 months and as needed with significant change in condition; requires registered nurse signature

• Determine members of the individual’s interdisciplinary team

• Determine level of risk

• Determine member’s goals

• Assign member to a clinical team

Assessment

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SENIOR CARE OPTIONS Assessment

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SENIOR CARE OPTIONS

• Individualized care plan driven by member’s goals

• Build from current strengths and support systems

• Augment as needed with interventions that address high risk areas

• Interventions address specific goals; reevaluated routinely and as needed whenever there is a significant change in condition

Care Planning

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SENIOR CARE OPTIONS

• Who is on this member’s team?

• Interdisciplinary team meetings

• Communication

• Goal of team is to educate member to areas of high risk and early identification of opportunities for maximizing quality of life and achieving personal care goals

Interdisciplinary Team

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CASE STUDY

• Sue, 81 yo, with schizophrenia, COPD, and neurogenic bladder, requiring self-catheterization and assistance with addressing med adherence

• At very high risk for both URI/UTI. Decompensates quickly. Referred to Commonwealth Care Alliance by PCP following 4 hospitalizations in 2010–2011

• NP and RN visit frequently (17 visits in 2011). Goal is to identify changes from baseline early and confers with PCP regarding acute concerns

• During a routine visit, clinical team, including the GSSC, noted increase in impulsivity and worsening of prescribed medication adherence

• As a new intervention in Sue’s care plan, the team changed her home medication delivery plan to a pre-packaged unit dosing system which simplified her routine

• COPD exacerbations are successfully treated at home by the clinical team

• Behavior health clinicians visit Sue in her home and provide ongoing support

• Hospitalized once in 2012

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STRATEGIES: COMMONWEALTH COMMUNITY CARE


COMMONWEALTH COMMUNITY CARE

• A specialized, not-for-profit, interdisciplinary practice focused on the complex primary care needs of individuals with significant physical and developmental disabilities

• 520 adult MassHealth-enrolled consumers with care team model • 162 consumers supported through affiliated physician private practices • Major diagnostic categories—cerebral palsy, spinal cord injury, multiple

sclerosis, muscular dystrophy, other neurological or developmental conditions

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COMMONWEALTH COMMUNITY CARE

• Individualized, consumer-directed care

• Focus on enhancing function and supporting individuals to live independently in the community of their choice

• Preventive health strategies, management of chronic conditions and prompt responsiveness to new problems

• Comprehensive 24/7 access to care in home, office, or hospital

Our Commitment

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CONSUMER-DIRECTED HEALTH CARE

• Our programs are designed to create partnerships between those receiving care and those providing care

• Emphasizes the ability of people to:

– Assess their own needs – Make choices about what services would best meet those needs – Monitor the quality of those services

• Supports the dignity of risk and the right of self-determination

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LESSONS LEARNED

• Interdisciplinary care team

• Community outreach and integration

• Person-centered approach to partnership

• Integration of hospital care and primary care teams to improve transitions

• Emphasis on long-term services and supports

– Consumer-directed personal care – Flexible durable medical equipment (DME) benefit

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THE TEAM

• Nurse practitioners/physician assistants, registered nurses

• Physicians

• Social workers/behavioral health specialists

• Rehabilitation specialists: PT/OT

• DME specialists

• Administrative support staff

• Outside specialists and consultants

• Hospital team

• Health outreach workers

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HOSPITAL SERVICE

• Designated hospital floor for all member admissions to Boston Medical Center

• Designated hospitalist MD/NP/PA team • Hospitalist serves as attending of record on the unit and as medical

consultant or care coordinator when patients are off service • Coordinate emergency department care and triage to most appropriate

setting including SNF or home • Daily communication with the outpatient team updating status and planning

for discharge • Coordinate direct admissions with the outpatient team as appropriate • Integration of personal care attendants

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Strategies


HOSPITAL PILOT

To integrate the care of PCAs into the hospital care system when appropriate to achieve the following goals:

• Improve hospital care for individuals who participate in the PCA program

• Reduce strain on valuable hospital resources specifically the nursing staff

• Reduce lengths of stay

• Improve transitions in and out of the hospital by allowing for the continuity of PCA care and support

• Promote autonomy, independence, and function to the maximal extent possible to all members in all settings

Personal Care Attendants

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PCA SCOPE OF PRACTICE

Personal care attendants may care for patients when the patient has been admitted to Boston Medical Center, based on a care plan agreed upon and signed by the patient or guardian, PCA and BMC registered nurse

• The clinical tasks the PCA will be allowed to perform will be based on:

– The patient’s clinical condition – The patient’s current medical diagnoses – Appropriateness of the tasks related to the patient’s current needs – Patient preference

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PERSONAL CARE

• Particular symbolic significance with the independent living movement for individuals with physical disability

• The consumer-directed approach makes PCA care a model service for the independent living movement

• The PCA is recruited, hired, trained, supervised, and, if necessary, fired by the consumer

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NATIONAL COUNCIL ON DISABILITY

“Studies of consumer direction indicate positive outcomes in terms of consumer satisfaction, quality of life, and perceived empowerment. There is no evidence that consumer direction compromises safety—in fact, the opposite appears to be true. Individuals who have participated in consumer-directed systems express strong preference for consumer direction and satisfaction with their care.” (2004)

Conclusions

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DURABLE MEDICAL EQUIPMENT

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Key to independence and quality of life


$840

$591

$728

$285

$142

$614

$136 $151 $114

Integrated Primary CareAcute Hospital InpatientDurable Medical EquipmentPharmacyBehavioral HealthOtherHome Health CareSpecialistsNon acute inpatient

EXPENDITURES

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Total PMPM Expenditures (excluding PCA Support) = $3,601

Note: Integrated primary care and DME are the priorities for expenditures. Hospital inpatient expenditures are 16.4% of the “pie” compared to >50% seen in Medicaid claims analysis for unmanaged FFS care.

N= 270 Member Years

Other $PMPM includes: • Lab/Radiology • Emergency room • Facility charges • Transportation, etc.


PHYSICAL & OCCUPATIONAL THERAPISTS • Integral to optimizing function and ensuring a safe home environment

supporting independence and independent living

• Teach patients home exercise programs

• Provide consultation regarding equipment such as wheelchairs, shower chairs, lifts

• Provide home safety evaluations

• Assess risk for pressure ulcers and determine effectiveness of seating systems through pressure mapping

• Coordinate outpatient services such as seating clinics

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PHYSICAL & OCCUPATIONAL THERAPISTS • CCC’s therapists are involved directly in all wheelchair assessments and

purchases for the purpose that appropriate equipment is ordered. Home trials of recommended equipment are required with PT/OT evaluation and input. CCC therapists are RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) certified as Assistive Technology Professionals

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DME STRATEGIES

• Flexible benefits for medical/surgical supplies; individualized decisions regarding quantity limits and types of supplies needed

• Include a wound care specialist on the team for consultation

• Waive authorization requirements for routine wheelchair repairs to minimize barriers to necessary service

• Equipment maintenance programs to maximize the life and functioning of equipment including back up wheelchairs

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SUMMARY

• Consumer-directed primary care addresses the systemic deficits experienced by consumers with LTSS needs

• Primary care is routinely ineffective or nonexistent—members take more time; present with multiple, complex issues; require more physical space; and adaptive equipment

• Predictable array of secondary complications are cause of functional decline, recurrent hospitalizations, poor outcomes and most costs

• Reliable personal care and appropriate durable medical equipment (especially wheelchairs) are essential and must be accessible to and integrated with medical care

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SUMMARY

• Typical MCO network, contracting, benefit design, utilizations management and care coordination strategies are at best irrelevant and at worst dangerous

• The historic LTC, BH and medical care “fire walls” are a major contribution to poor care, high cost and premature death

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TESTIMONY

“Twenty two years ago I was in a car accident that left me paralyzed from the neck down. Thirty days in a coma, little did I know I would be waking up into a life changed forever. Following my accident, I was overwhelmed by the enormous amount of care that I needed on a day to day basis. And the cost of my care was insurmountable … As a person with extremely limited movement, I continuously face a greater number of challenges in performing daily living activities. An added challenge is being non-vocal. Very few people take the time to listen to what I am trying to say … CCC has allowed me to live independently. My nurse practitioner will make home visits and is available on-call 24 hours a day … Without CCC, I would just be another patient in a hospital or a nursing home with NO voice and NO input into my own care. That is NO WAY TO LIVE! If it was not for CCC I know I would not be here today.”

• NO HOSPITALIZATIONS SINCE 2004

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TESTIMONY

“Both myself and my twin sister have muscular dystrophy and are wheelchair users. Because I am cared for by CCC, I have a physician’s assistant whom I can call at any time. Once when I was very sick with a fever, I called her and after talking, she ordered an ambulance to take me to the hospital. She and my primary care doctor at CCC were at the emergency room when I arrived. That made me feel safe. I was diagnosed with pneumonia, and after I went home, my PA called every day to see what I was eating and drinking. Many years ago, I was petrified of doctors because most doctors don’t understand people with disabilities. Sometimes they would talk down to me as though I didn’t know what they were saying. When I joined CCC, I was truly amazed how ALL the doctors, nurse practitioners, PAs, physical and occupational therapists, and the DME department respected me as a person and listened to what I had to say. They all have made my life so much better.”

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TESTIMONY

“Commonwealth Community Care has a unique collaborative approach to administering care … these practitioners have very specialized knowledge in the field of adults with disabilities. The knowledge evolves from combining their smarts with a respect for the experience and know-how of consumers. It results in very powerful stuff. We stay out of hospitals. We stay home and away from emergency rooms visits. We do not feel alone. We do not feel misunderstood. We feel like participants in our own destiny. And this just builds on itself. The more ownership you feel in your care, the more invested you are in staying well…”

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QUESTIONS?


CONTACT

Commonwealth Care Alliance commonwealthcarealliance.org

• Leanne Berge, Senior Vice President, One Care Program

[email protected]

• Cheryl Pascucci, MS, FNP-BC, Clinical Director

[email protected]

Commonwealth Community Care commonwealthcommunitycare.org

• Mary Glover, MSN, ANP-BC, Executive Director

[email protected]

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http://www.commonwealthcarealliance.org/

mailto:[email protected]


http://www.commonwealthcommunitycare.org/


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LESSONS FROM THE FIELD - advancingstates...LESSONS FROM THE FIELD CREATIVE STRATEGIES FOR INTEGRATING SERVICES AND IMPROVING QUALITY OF CARE FOR ELDERS AND ADULTS WITH DISABILITIES