Long-Term Care Long-Term Care IntegrationIntegration

in San Mateo Countyin San Mateo County

Jean FraserJean Fraser

Maya AltmanMaya Altman

March 10, 2011March 10, 2011

Long-Term Care Integration Long-Term Care Integration Core ConceptsCore Concepts

►Emphasize home and community-based services to allow individuals to remain in community settings

►Consolidate preventive, primary, acute, Long-Term Care, and Home- and Community-Based services and funding

►Allow more local control and flexibility►Eliminate administrative duplication

and complexity

Core Concepts (continued)Core Concepts (continued)

►Enhance assessment, care planning, and medical management

►Establish smooth and appropriate transitions between levels of care

►Reinvest savings back into San Mateo County community

►Improve service delivery and access to care

Goals: Long-Term Care Goals: Long-Term Care IntegrationIntegration

►Person-centered care►Improved health &

quality of life►Greater access to home and

community-based services►Lower number of premature

nursing home placements

Current SituationCurrent Situation

80 year old Living alone

Multiple chronic health problemsDeclining at homeSocially isolated

Chronic lack of support leads to hospitalization

Discharge to nursing home

No coordinated care

Person unable to reside at home alone

Result

Lack of long-term planning

Lives in an institution

Very expensive care

Barriers

Future of Long-Term CareFuture of Long-Term Care

80 year old Living alone

Multiple chronic health problemsDeclining at homeSocially isolated

Primary care providers connect with case manager for long-term care assessment

Services selected based on need and long-term care plan

Support provided in the home

Result

Improved health

Lives in most integrated setting

More cost efficient

Why now?Why now?

San Mateo County is facing a San Mateo County is facing a huge increase inhuge increase inolder adults. older adults.

Minus a fully coordinatedMinus a fully coordinatedsystem, more people will system, more people will fall through the cracks.fall through the cracks.

Work Toward Long-Term Care Work Toward Long-Term Care Integration in San Mateo CountyIntegration in San Mateo County

YearYear MilestonesMilestones1980s 1980s and and 1990s1990s

• San Mateo County consolidation of HCBS in Health San Mateo County consolidation of HCBS in Health System System

• Creation of Commissions on Aging and DisabilitiesCreation of Commissions on Aging and Disabilities• SMC, HPSM, and SMC Hospital Consortium propose LTCI SMC, HPSM, and SMC Hospital Consortium propose LTCI • IHSS Public Authority Advisory CommitteeIHSS Public Authority Advisory Committee

20032003 • SMC selected as pilot for Uniform Assessment ToolSMC selected as pilot for Uniform Assessment Tool• County hospital Senior Care Center Opens (Ron Robinson County hospital Senior Care Center Opens (Ron Robinson

SCC)SCC)

20062006 • HPSM Medicare CareAdvantage operations beginHPSM Medicare CareAdvantage operations begin• CareAdvantage subcontract with SMC Behavioral Health CareAdvantage subcontract with SMC Behavioral Health

and and Recovery ServicesRecovery Services

20082008 • Partnership with CalOptima in Orange County to advocate Partnership with CalOptima in Orange County to advocate for LTCI in both countiesfor LTCI in both counties

20102010 • LTC institutional benefit added to HPSMLTC institutional benefit added to HPSM• HPSM initiates clinical care management in nursing HPSM initiates clinical care management in nursing

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HPSM serves 95,000 people through six programs.

59,000 members

42% of whom areseniors and disabled

8,000 of whom areSpecial Needs Plan members

California

San MateoCounty

HPSM Medicaid

CareAdvantage (Special Needs Plan)

• 8,000 enrollees (60% of those eligible)• Member benefits

– Dental and vision care– Transportation for medically related services– Subcontract with County Behavioral Health

• Customer service– Staff dedicated to and expert in serving older and disabled

members– Staff fluent in Spanish, Chinese, Tagalog, and Russian– Help for members in navigating the Medicaid / Medicare

maze– Assistance in maintaining Medi-Cal status

• <1,000 people “saved” from losing Medi-Cal in past year• Work with Legal Aid to help people with share of cost

CareAdvantage (con.)

• Care management– Identification of members at high risk– In home physician visits– Help with managing medications– Care transitions between hospital and home– Connecting members to medical homes– Interdisciplinary care coordination teams– Case conferences with County Behavioral

Health and Aging and Adult Services / IHSS– Clinical management in long term care

facilities

Medicaid Funded ServicesAcute Medical / Ancillary Care

(HPSM/County)

Institutional Long Term Care

(HPSM as of Feb 2010)

Home & Community Based

Services (Many operated by

County/FFS)

Outpatient/Clinic Based Primary Care

Distinct Part Skilled Nursing Facilities

In-Home Supportive Services (IHSS)

Specialty Medical Care/ County Mental Health Services

Freestanding Nursing Homes

Multipurpose Senior Services Program (MSSP)

Ancillary Services (Lab, pharmacy, radiology, durable medical equipment)

Caveat: Reimbursement only with LTC aid code

Hospice, Adult Day Health Care, Adult Day Care, Alzheimer’s Day Care Resource Centers

Inpatient Services

Services combined into LTCIServices combined into LTCI

Skilled Nursing

PACE

MSSP

In-Home Care

Adult Day CareNutrition

Mental Health Alcohol & Other Drug

Skilled Nursing

Model for LTCIComponent Options

Population • All adult Seniors and Persons with Disabilities (SPDs)

Medical Criteria • Eligible for nursing home level of care• At risk for nursing home level of care in the near term

Coverage • Dual eligible enrolled in CareAdvantage• Medicaid only• Dual eligible not enrolled in CareAdvantage

Assessment • Uniform assessment tool for all integrated services

Model for LTCI—ContinuedComponent Options

Acute Services • All Medicaid primary and acute care• All Medicare primary and acute care for duals in

CareAdvantage

Long Term Care • Medicaid nursing facility services• Medicare nursing facility services for CareAdvantage duals

HCBS • All Medicaid HCBS: Adult day health care Personal care (IHSS) MSSP

• “In Lieu” Services, e.g.:Services in assisted livingServices in Board and Care

Expanded TransportationHome modifications

Model for LTCI—Continued

Component Options

Medical Home • Primary Care Medical Home (enhanced primary care)

Interdisciplinary Team

• Member specific teams• Member is part of the team• Personal care worker may be part of the team

Individual Care Plan • Address physical as well as psychosocial needs• Accessible by all• Member involved in development of plan

Case Management • Case management based on individual care plan

Model for LTCI—ContinuedComponent Options

Community Services • Leverage existing San Mateo County Health System and community resources

• Integrate services already available

Enhanced Data • Single initiative to track and trend interventions / outcomes

Public Authority • Contract with Public Authority for personal care services

Stakeholders • Program oversight by local stakeholders

What Will Be Different?What Will Be Different?

NowNow LTCILTCIOne place to go for helpOne place to go for help

One uniform assessment for all One uniform assessment for all servicesservices

Variety of options available with Variety of options available with focus on keeping people in the focus on keeping people in the most home-like environmentmost home-like environment

System for MD and community System for MD and community agencies to refer patients who agencies to refer patients who need help before they decline & need help before they decline & need hospital careneed hospital care

Patient is the decision-makerPatient is the decision-maker

Questions?Questions?