San Diego Long Term Care Integration Project

April 14, 2004

LTCIP Planning Committee Meeting

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Announcements Aging Summit: April 19, 2004, 7:30-

3:30, San Diego Concourse Next Planning Committee Meeting: May

4, 2004, 10:30-noon, County of SD, 8965 Balboa Ave, Conference room (1st floor)– Community Education Kick-off– Chair: Betty London

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Community Planning Process

From 50 to 600+ key stakeholders over past 5 years: 12,000+ hours

Seeking to improve system of care for consumers and providers

Planning within state LTCIP authorization (form follows funding)

San Diego County Board of Supervisors&

State Office of Long Term Care

Jean Shepard, Acting DirectorCounty of San Diego, Health & Human Services

Agency, (HHSA)

Advisory Group:Goal: Make final decisions and

recommendations for inclusion in the plan.

Planning Committee:Goal: Guide the LTCIP planning process.

Suspended Workgroups pending service delivery

model decision

Suspended Workgroups pending service delivery

model decisionHealth Plan Partners

Workgroup

Health Plan Partners Workgroup Finance/Data

Workgroup

Finance/DataWorkgroup Options Workgroup

Options Workgroup

Internet• Facilitates

communication• Provides broad public

education

Pamela B. Smith, Project DirectorEvalyn Greb, Project ManagerAging & Independence Services

Lead County Agency

MH & SAWorkgroup

MH & SAWorkgroup

Explore use of the Healthy SanDiego model for potentialService delivery system for LTCIP.

Determine the financialfeasibility of the proposedLTCIP for San Diego County.

Make recommendation to Planning Committee re: inclusion of mentalhealth and substance abuse services in LTCIP.

Incremental LTCI Strategies:1) Network of Care2) Physician Strategy3) Health Plan Pilots

Governance-Case Management-Info/Technology-Quality Assurance-Scope of Services-Workforce Issues-Community Network Development-Developmental Disabilities

Community EducationWorkgroup

Community EducationWorkgroup

Explore use of public health education models that promote improved chronic care management for LTCIP

Long Term Care Integration Project

Organizational Chart & Decision Tree

April 2004

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San Diego Stakeholder LTCIP Vision for Elderly & Disabled Develop “system” that:

– Provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus

– Pools associated (categorical) funding– Is consumer driven and responsive– Expands access to/options for care– Utilizes existing providers

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Stakeholder Vision (continued)

– Fairly compensates all providers w/rate structure developed locally

– Engages MD as pivotal team member– Decreases fragmentation/duplication

w/single point of entry, single plan of care– Improves quality & is budget neutral– Implements Olmstead Decision locally– Maximizes federal and state funding

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Mrs. C

84 year old woman lives alone CHF, HTN, diabetes, hearing and vision

loss, IADL dependencies 16 medications by 6 MDs Medicare and Medi-Cal beneficiary Only child lives in Chicago

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Client Referral Patterns

9Journal of the American Geriatrics Society, Feb. 1997

In-HomeServices

DayHealthCare

AcuteHospital

TransitSkilledNursingFacility

MedicalSpecialty

MealsService

PrimaryCare

MRS.C.

Ideal System

Mrs. C & Care

Manager

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From Vision to Service Delivery Model… Explore Healthy San Diego due to:

– Access, education, prevention– Advocacy– Cost-effectiveness– Population-based– Existing infrastructure– Stakeholder-designed, BUT

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HSD Expansion Areas…

Tailor the program for chronic care of aged and disabled persons

Provide “wraparound” services Provide chronic care management on a

population basis Receive adequate reimbursement via

Medi-Cal or Medi-Medi dual cap

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Where are we now?

May ’02, BOS: “give us 3 options” Since then: Dr. Mark Meiners assists

w/strategies development:– Network of Care– Physician Strategy – HSD Health Plan/Pilot Projects

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Network of Care Beta testing with

– consumers and caregivers– community based organizations– other providers, Call Center staff

Develop “continuous quality improvement” Support 2 service delivery models Measure behavior changes of providers and

consumers Assess potential as HSD+ info and

communication database

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Physician Strategy

Partner w/physicians vested in chronic care Develop interest/incentive for support of “after

office” services (HCBC) Identify care management resources to

support physicians/office staff to link patients and communicate across systems

Train on healthy aging, geriatric/chronic disease protocol, pharmacy, HCBC supports

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Physician Strategy (cont.)

The California Endowment has provided resources for planning

Focus groups planned w/MDs, other providers, and consumers

Implementation Plan for review by 6-05 PS implementation 7-06 with HSD+ Current HeartPartners opportunity

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Health Plan Pilots

Pilots to do small, voluntary models of care integrated across the health, social, and supportive services continuum:– Private entity to contract with State through

RFP with stakeholder support (AB 2822)– Healthy San Diego Health Plans to develop

phase-in with rate cells adjusted for function and setting = HSD+

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Consultant Team for AAP

Dr. Mark Meiners, National Program Director, RWJ Medicare/Medicaid Integration Program

Mercer Government Human Services Consulting

LTCIP Staff and Stakeholders

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Administrative Action Plan for Healthy San Diego Plus (HSD+)

1. “Vision” for chronic care system

2. Governance and administration

3. Population, services, delivery system

4. Care management and integration

5. Financing and cost neutrality

6. Quality management & improvement

7. Integrated information system

8. Phase-in strategy

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AAP Highlights

Begin voluntary enrollment July ‘06 for 300 elderly per month, Medi-Cal or Medi-Medi

Use rate cells adjusted for care setting and functional level

DHS & CMS contract with extensive provider networks (health & social services)

Care manager & enrollee at “hub” Quality control mechanisms required

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Overview: Milestones and Target Dates

Draft AAP discussion w/ LTCIP PC (today) Update County BOS (5/04) Revise AAP; Gain consensus (4/04-6/04) Submit County-approved AAP to DHS OLTC

(6/30/04) Present concept paper to CMS (9/04) Waiver approved(s) (7/05) State contract awards determined (2/06) Pre-enrollment activities (3/06-5/06) Begin Phase I implementation (7/06)

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Governance and Administration

Expand HSD Infrastructure: Operating Agency and Governing Body

Pre-qualify Provider Networks through RFSQ process

3-way contract: DHS/CMS/Provider Network Medicare/Medi-Cal caps pooled at plan level System mgmt – County BOS, HHSA Director Service mgmt – contracting provider network

HSDJoint Consumer &

Professional Advisory Committee

HSDProgram Manager

County of San Diego, HHSA Director 

Policy & Program Support Division Deputy Director

Medical Care Program Administration Senior Program Manager

HSD+Program Manager

Analysts III 

Analysts II 

Sup Com Hlth Prom Specialists 

Sup Com Hlth Prom Specialists 

HSD+ Organization Chart

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Governance & Administration: Milestones and Target Dates

Expand membership of Joint Committee (1/05-1/06)

Present/discuss draft of RFSQ (6/05) Finalize and release RFSQ (9/05) Complete RFSQ evaluations and forward to

State (1/06) Perform readiness review of contractors (2/06-

4/06) Train additional HSD+ staff; make other

systems modifications (1/06-12/06)

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Population, Scope of Services, Delivery System

Begin with elderly (65+); phase in younger disabled at later date

All Medicare & Medi-Cal state plan services(State plan services for Medi-Cal only). Plus value-added home and community-based services.

Provider networks responsible for network development & coordination

MOU’s for frequently used off-plan services Consumer Interface/ Cultural Competence Demonstration of stakeholder support

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Population, Services, Delivery System: Major Milestones and Target Dates

Complete Population and Scope of Services forms (10/04)

Establish budget neutrality criteria (12/04) Establish provider network requirements (4/05) Develop policy regarding off-plan service

coordination (6/05) Finalize call center consumer interface protocols

(1/06-4/06) Define “complex care needs” (6/05) Update/expand MOU’s (1/06-6/06)

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Care Management & Integration

Care manager & enrollee at “hub” of system Provider Networks sub-contract for care

mgmt w/ AIS and/or CBO Care mgmt standards will be specified in

RFSQ “No wrong door” entry to AIS Call Center for

eligibility & options counseling Standardized assessment by contractor to

determine level of care Contractor/Consumers engaged in chronic

care self-management (Com. Ed Workgroup)

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Care Management & Integration: Milestones and Target Dates

Define minimum care mgmt & integration standards for RFSQ (1/05)

Define minimum contents of Integrated Care Plan (3/05)

Determine standards for Contractor evaluations of care manager (5/05)

Define contents and accessibility of care mgmt database (5/05)

Develop web-based data system to support chronic disease self-management (5/06)

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Financing and Cost Neutrality

Dual funding from Medi-Cal and Medicare will allow a single contractor to provide the most appropriate and cost-effective combination of services for individuals

Multiple Medi-Cal capitation cohorts (to match reimbursement to risk)

During first phases of implementation offer risk sharing and/or stop-loss mechanisms to contractors

Medicare capitation structure still to be negotiated Rates that are developed must be budget neutral to

be approved

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Financing and Cost Neutrality: Milestones and Target Dates

Contract/plan in place for actuarial support (9/04) Review detailed reimbursement approach with LTCIP

Planning Committee and potential contractors (12/04) Perform cost analysis for budget neutrality (1/05) Perform gap analysis of system(s) requirements

related to reimbursement approach (2/05) Obtain State approval of reimbursement approach

(3/05) Begin capitation rate development process (4/05) Final capitation rates developed (12/05)

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Quality Management & Improvement

Contractors will be required to demonstrate utilization review and management processes

Contractors will have primary responsibility for resolving complaints and appeals (grievances), however other levels of review will exist

RFSQ will specify reporting related to quality – focus on outcomes and performance improvement

RFSQ will specify quality improvement initiatives External surveys and reporting will be performed

such as EQRO, HEDIS, and CAHPS

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Quality Management & Improvement: Milestones and Target Dates

Define the complaint and appeals protocol (1/05) Define County’s method/process to monitor quality

management requirements (2/05) Develop policies and standards of utilization review

and management for RFSQ (3/05) Define required QM reporting for RFSQ (4/05) Determine Contractor standards for provider

credentialing and provider profiling Draft materials to be provided in writing to consumers

about the complaint and appeals process (1/06)

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Integrated Information System Web-based system that supports the integration of

care across the continuum of providers of health, social, and supportive services

Contractors will be required to collect and retrieve data on an individual patient basis and in the aggregate

Pre-implementation planning will examine the Network of Care component as a potential vehicle to be the over-arching information and communication system

Two data support programs will be expanded for the aged and disabled population – Panorama View and GeoAccess

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Integrated Information System: Milestones and Target Dates

Perform a gap analysis of system requirements against current system capabilities (2/05)

Plan with stakeholder to expand Panorama View and GeoAccess capabilities (3/05-5/05)

Define contents and accessibility of case management database (5/05)

Systems modifications and/or development (1/06-12/06)

Develop web-based data system to support chronic disease self-management (5/06)

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Phase-in Strategy

Begin with voluntary enrollment of age 65+ to allow time for contractors to build expertise, an adequate network of providers, and infrastructure

Determine evaluation criteria with baseline data and benchmarks to measure the success of phases and to be able to justify moving to the next phase

Goals and performance criteria for each phase will be established and continuously modified with implementation

Implementation of program will be completed in no more than four phases (maybe fewer)

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Phase-in Strategy: Milestones and Target Dates

Define evaluation plan criteria for baseline data and benchmarks for Phase I (1/06-5/06)

Enrollment of members with contractors (5/06-6/06) Phase I implementation begins for 65+ in greater

metro San Diego (7/06) Phase II implementation begins, 65+ in entire County

(7/08) Phase III implementation begins, ages 21+ in entire

County (7/10) Phase IV, mandatory enrollment begins (7/12)

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Questions & Comments