Role of Medical Case Management in A New Health Care Environment

TECHNICAL ASSISTANCE TO

ADAPTING RW TO THE ACA

Presented by the Newark, NJ EMACity of Newark, Dept. of Child and Family Well-Being/ Ryan White Unit

TECHNICAL ASSISTANCE TO ADAPTING RW TO THE ACA- ROLE OF MEDICAL CASE MANAGEMENT IN A NEW HEALTH CARE

ENVIRONMENT

Workshop Faculty

• Ketlen Alsbrook, MPA- Newark EMA Project Director

• Shanon Mettlen, MPA- Union County Grant Coordinator

• Sharon Postel, MBA, JD- QM Consultant

SUPPORT DISCLOSURES

This continuing education activity is managed and accredited by Professional Education Service Group. The information presented in this activity represents the opinion of the author(s) or faculty. Neither PSEG, nor any accrediting organization endorses any commercial products displayed or mentioned in conjunction with this activity.

Commercial Support was not received for this activity.

FACULTY DISCLOSURES

• Ketlen Alsbrook

Has no financial interest or relationship to disclose

• Shanon Mettlen

Has no financial interest or relationship to disclose

• Sharon Postel

Has no financial interest or relationship to disclose

• CME Staff Disclosures

Professional Education Services Group staff have no

financial interest or relationships to disclose.

LEARNING OBJECTIVES

At the conclusion of this activity, the participant will be able to:

1. Examine the role of MCM in the current and “new” healthcare environment.

2. Identify how RW CLD and CQM systems can enhance coordination of care and NHAS efforts.

3. Develop MCM strategies and tools to continue and enhance the vision of the RWHAP

AFFORDABLE CARE ACT

Key provisions:

• Universal coverage; mandates provision/ acquisition of health insurance

• Eliminates annual/ lifetime limits on coverage and exclusion of those w/ pre-existing conditions

• Premiums must cover at least 80% of medical care costs and include preventive care

• State chosen benchmark plan covering 10 federally mandated health categories.

• Accountability Care Organizations (quality, efficiency & cost per pt)

• May reduce uninsured from 19% to 8%

IMPACT ON NEMA RW RECIPIENTS

• NJ Medicare• Eliminates Part D donut hole and overpayments

• No copay or deductible for preventive care

• 12% of Part A/F recipients have Medicare

• New Jersey Medicaid • Expands income limits from 78% to 133% FPL.

• 1/3 of Part A/F recipients have some form of Medicaid

• Add’l 3,300 clients eligible for Medicaid after expansion (165% increase from 2.5K to 5.3K).

• Insurance Exchanges• Managed care programs for individuals and employers with >50 workers

• Out of pocket costs on a sliding scale of 2% to 9.5% of annual income

• Approx. 1,000 Part A/F clients (134% - 500% of FPL) may be covered

NEMA EPIDEMIOLOGICAL PROFILE

• 13,476 PLWHA – 2 million population

• 69% Afr Amer, 17% Hispanic/Latino, 12% White

• 40% female

• Heterosexual, IDU, MSM exposure

• 5 counties in northern NJ – urban, suburban/rural

• Only EMA in NJ. (3 TGAs + Philadelphia PA EMA which covers part of NJ)

• EMA has 38% NJ PLWHA but only 24% NJ population

• Newark – 5,858 PLWHA of 277,000 population – 2.1% prevalence vs. 0.4% US

• 16% of NJ epidemic but 3% of population

• 30 CASE MANAGEMENT AGENCIES serving 6,000 clients.

• CM definition included both medical and non-medical functions.

• Agencies could do medical OR non-medical OR both. “Hybrid.”

WHERE WE WERE (PRE- RWTEA)CASE MANAGEMENT

A range of client-centered services that links clients with primary medical care, psychological and other services to ensure timely, coordinated access to medically-appropriate levels of health and support services, continuity of care, ongoing assessment of the client’s and other family members’ needs and personal support systems and inpatient case management services that prevent unnecessary hospitalization or that expedite discharge, as medically appropriate, from inpatient facilities. Key activities include initial comprehensive individualized service plan; coordination of services required to implement the plan; client monitoring to assess the efficacy of the plan; and periodic reevaluation and revision of the plan as necessary over the life of the client. May include client-specific advocacy and/or review of utilization of services. (See Case Management Standards document for more detailed information regarding case management services).

CASE MANAGEMENT DEFINITION (PRE- RWTEA)

NEMA CORE SERVICE MODEL (PRE-RWTEA)

WHERE DID WE WANT TO GO?

All CM agencies had to be split by new DISTINCT functions … FROM OVERLAPPING FUNCTIONS.

CARE Act Case Management

RWTMA Non-Medical Case

Management

RWTMAMedical Case Management

HOW WE PREPARED

• Medical Case Management

• Client Level Data (CLD) System

• Quality Management

• Programmatic & Fiscal Monitoring

• Ongoing scan of healthcare environment (pre-ACA)

• Must be provided by trained professionals (medically credentialed and otherwise)

• Timely/ Coordinated care plans that link clients to medical care, psychosocial and other services

• Initial assessment

• Development of care plan

• Coordination of services

• Continuous monitoring

• Periodic re-evaluation and adaptation

• Continuity of care

• Treatment adherence counseling

• Advice and assistance in obtaining medical, social, community, legal, financial, and other needed services.

• Non-medical case management does not involve coordination and follow-up of medical treatments.

CLEAR DEFINITION AND RESPONSIBILITIES FOR CM-NM AND MCM

CASE MANAGEMENT- NON MEDICAL MEDICAL CASE MANAGEMENT

PROGRAM CHANGES

MCM = Medical providers only (approx. 15 agencies)

PMC providers must apply for or demonstrate provision of MCM

CM-NM = CBOs, non-medical agencies (15 additional agencies)

Exceptions= Partnerships/Collaborations

Allows experienced CM agencies to do MCM for small medical providers who cannot support (FT/PT) MCM staff.

Planning Council updates to Standards of Care for PMC & CM-NM

Train MCM and CM-NM staff on expectations, responsibilities, etc.

Provide ongoing training.

CONCERNS

• Not all CM agencies could do MCM.

• 75%-25% split core medical services (MCM) and support (CM-NM)

• CBOs were concerned about funding.

• Shifting of RW resources to non community based providers.

• Sustaining CM programs that exceed CM expectations

NEMA CORE SERVICE MODEL- POST RWTEA

BENEFITS

• Reduce duplication of effort.

• Retain high performing agencies.

• Attainable goals; realistic expectations

• More effective system – MCM have support of [CM-NM] agencies with more knowledge of community resources.

INFORMATION TECHNOLOGY (IT) – CLD

• Nuclear Option (Payor of Last resort controls)

• Referral tracking system to improve coordination between RW and non-RW providers

• 9-month alert for follow up/ retention in care.

• Exception report for MMC, Medicare, lost clients, etc.

• Automated feed of EMR to CLD.

• CHAMP user subcommittee

OTHER QUALITY MANAGEMENT TOOLS

• Newark EMA CQM Plan• HRSA HAB Core Clinical Performance Measures

• Expand from 5 measures to Group 1, 2 , 3 and In+Care• Extend required fields from PMC to MCM (most likely to

enter/record data)• Performance measurement and monitoring using RSR Ready

Vendor System. • Expand CQM Chart reviews – Adding MCM in addition to PMC• Early Intervention and Retention Collaboratives (EIRCS)

OUR MCM VISION

• MCMs as “integral part of care system”

• Interventions- patients new, existing and lost to care

• Benefits Coordination

• MCM support of all PLWHA receiving PMC regardless of patient’s source of insurance.

• MCM as the focal point of IT system. Shift from PMC OR in addition to PMC. (HAB Performance Indicators)

MCM SCOPE

• ENTRY INTO CARE • Identify, Inform, Referral and Linkage (EIIHA and EIRCS)

• ENGAGEMENT IN CARE• Development of care plan, follow up, treatment plan updates

• RETENTION IN CARE.• Filling in gaps, navigating the system, insurance affordability

• TREATMENT ADHERENCE • Keeping appointments, medical monitoring (CD4, VL, medication regimen &

complications), VL Suppression

FY 13 Newark EMA Ryan White Part A Program

BENEFITS COORDINATION INITIATIVE Updated: 9/11/12

BENEFITS COORDINATION TEMPLATE This template can be used for 3 purposes:

1/ As an individualized care plan checklist for each client. (Service columns only.)

2/ For an individual client, to determine funding source of benefits and needed coordination between funding programs.

3/ For an agency to determine total resources available and needed by funding source

SERVICE NEED Needed? Funding Source

Service Type General Subtype Y N MMC Medi- caid G Medi-care VA Pvt Ins Charity RW A RW B RW C

1 Medical Care Outpatient

Physician visit

Nurse visit

Labs

Inpatient

Long Term care

2 HIV Medications ADDP

APA

Other

3 Mental Health Outpatient

Inpatient

4 Substance Abuse Outpatient

Residential

Inpatient

5 Oral Health

12 Housing Emergency

Transitional

Long Term

13 Food Delivered Meals

Food Bags

Food Vouchers

14 Financial Assist. Emergency

Financial Benefits

15 Legal Assist.

16 Respite Care

CHALLENGES

• Uncertainty

• Relationships with Medicaid managed care, HMO’s, etc.

• Referrals from PCP to access specialty care

• Copays, deductibles, etc.

• Prior authorization for non- HIV medications, treatments, etc.

• Decreased CQM controls

PROGRAM & FISCAL MONITORING

• Implementation of National Monitoring Standards

• Assessing the landscape

• Use of CLD for monitoring program and fiscal performance

• Modifications to Site Visit format, program assessments and corrective actions (more PDSA’s).

NEXT STEPS

• Prepare for seismic shift from RW PMC to MMC.• Assess the landscape

• Standardized MCM functions

• Review/ update MCM Training curriculum

• Make training available to CM-NM providers.

• Review/ update RSR Ready Vendor System as needed

• Benefits Coordination Initiative

• Develop relationships with NJ Medicaid, managed care programs, ACO’s, etc.

OBTAINING CME/CE CREDIT

If you would like to receive continuing education credit for this activity, please visit:

http://www.pesgce.com/RyanWhite2012