Working with Managed Care OACCA Conference

April 28, 2014

Timia DelPrete-Brown, Ph.D, LPCC-SDirector, High Risk Care Management

andJonas Thom, MA,PCC-SVP of Behavioral Health

OACCA ConferenceAgenda

• What is Managed Care?• Who is CareSource• CareSource Clinical Programs• High Risk Case Management• BH Programs and Covered Services• Opportunities for Collaboration• Q&A

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Mission: The CareSource Heartbeat

Making a difference in the lives of underserved people by improving their

health care

Vision CareSource Management Group will be an

innovative leader in the management of quality public sector health care programs

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What is Managed Care?• Ohio Department of Medicaid (ODM)

‒ A health plan that attempts to control the costs and quality of care

‒ Operates throughout the state of Ohio• “Hands-on health insurance"

‒ Combines the responsibility for paying for a defined set of health services with an active program to control the costs associated while at the same time attempting to control the quality of and access to those services.

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What is Managed Care?• CareSource

‒ Founded on quality and service

‒ Delivered with compassion

‒ Understands Medicaid, Medicare, and the associated regulatory environments

‒ Process efficiencies and

value-added benefits‒ HEDIS initiatives

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What is Managed Care?

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What is Managed Care?BH Services

• Ohio Medicaid BH Services

• OMHAS Services

• FFS/Managed Care Services

Who is CareSource?• The largest non-profit Medicaid managed

health care plan in Ohio• 2nd largest Medicaid managed health

care plan in the country• Established in 1989

– Then known as Dayton Area Health Plan, CareSource pioneered the state's first mandatory Medicaid managed care program in the Dayton area.

• URAC & NCQA accredited• Headquarters Based in Dayton, Ohio with

offices in Cleveland, Columbus, and Kentucky

• Recent partnership/alliance with Humana 8

• CareSource serves 950,000+ Ohio citizens

• CareSource contracts with 24,000+ Ohio providers

• CareSource employs 1,500+ individuals

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Who is CareSource?

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Care Source Health Services Division

Quality Improvemen

t

Pharmacy

Medical Managemen

tBehavioral

Health

Health and Wellness

Care Management• CareSource 24• Disease

Management• Care

Transitions/Bridge to Home

• High Risk Case Management

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CareSource Programs

Quality programs• HEDIS

• Support quality care

• Medical Management• Identify services/resources• Prior authorization management

• Quality Improvement• Entry point for member voice and

continuous quality improvement

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CareSource Programs• Disease Management

‒ Self Management‒High risk Asthma ‒Diabetes

‒ Different levels of DM ‒ Proactive calls‒ Minimum contacts

‒ Smoking Cessation‒Informal connection

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CareSource Programs

Triage/CareSource24

• Assess the severity of the member's symptoms and guide the caller to the appropriate level of care

 • Assists members in navigating the healthcare

system while educating and empowering the member. 

• 24 hours a day, 7 days a week

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The Care Transitions Program

• Bridge To Home:

• Contact each member having a hospital or skilled nursing facility confinement within 14 days of discharge– Adherence to scheduled primary/specialty care follow up care– Medication reconciliation and education– Identification of potential member gaps in understanding discharge

instructions or changes in the member’s medication regime post discharge

– Assessment and identification of member educational needs with a focus on member self-management and knowledge of the member’s individual triggers and individualized

care treatment plan

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CareSource Programs• Population Specific

‒ Coordinated Services/Care4U‒ Opiate RX abuse ‒ 12+ active RX, 4 docs/pharmacies‒ Care management and coordination

‒ Prenatal/NICU ‒ Manage high risk pregnancies‒ Child is in the NICU‒ ABD Children

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Who are the ABD Children?

• There are approximately 37,000 Ohio children who are eligible for Medicaid due to a disability

• On July 1, 2013, ABD children were enrolled in a one of Ohio’s Medicaid Managed Care Plans

• Exclusions included those eligible for Medicaid on waivers, children who reside in institutional settings, or children who received both Medicare and Medicaid benefits

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Developmental disorder Epilepsy PDD & Mood Disorders Bipolar disorder Deaf Anoxic Brain Damage Cardiac Septal Defects Traumatic brain injury Spina Bifida Substance Dependence Psychotic disorders Sickle Cell Blind Transplant Status Quadriplegia and paraplegia Cancer diagnosis

Top Complex Medical Conditions for Children:

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ABD Children's Advisory Council

• Developed in March 2012• Charged with providing CareSource staff and stakeholders with key

recommendations for ensuring children with special health care needs are successfully transitioned to the health plan

• Recommendations led in developing strategies for attaining the best possible health outcomes for these newly eligible children Parent Advocate Nationwide Children's Easter Seals BCMH Ohio Association of Children

Services Ability Center of Greater

Toledo

Family Voices Ohio Council of Behavioral Health &

Family Services Providers Children’s Defense Fund Voices for Ohio’s Children University Centers for Excellence in

DD Dayton Children’s Hospital Respite Coalition

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ABD Children's Top Chronic Conditions

• ODM compiled utilization data regionally and nationally (“Hot Spotters” article published in New Yorker magazine)

• ODM determined that a very small percentage of members are driving Medicaid (ABD & CFC) costs. Those individuals are known as “hot spotters”

• ODM mandated that all managed care companies operating in the State of Ohio revise their case management model to focus on the top 1% of “hot spotters”

Who Are High Risk Members?

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What Are the Program’s Requirements?• ODM’s Requirements:• Need-based guidelines• High Risk, top 1%• Mobile and community

based workers• Face-to-face &

telephonic interactions with members

• 1:25 staff/member ratio• Reimbursed for improved

health outcomes (HEDIS) 21

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High Risk Care Management: Community Based Model

Multidisciplinary team approach • Members/

Caregivers• Case

Managers• LPN’s• Social

Workers• Patient

Navigators• Care

Management Support Specialists

• PCPs and Specialists

• Community Partners

Integrates profession

al Standards of Practice

Coordination of

member’s health

care needs across care

continuum

Focus on quality

outcomes, regulatory

and accreditati

on requireme

nts

What is CareSource’s High Risk Case Management Model?• Incorporates the Case Management

Society of America and the American Association of Managed Care Nursing Standards of Practice– Commitment to the CM Process:

identification, assessment, planning, facilitation, monitoring, evaluation, & advocacy

• Integrates the Harold P. Freeman Patient Navigation model

• Integrates behavioral and physical health intervention strategies

• Utilizes a multidisciplinary team approach

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High Risk Case Management Components

Identification

• Predictive modeling

• Health risk assessments

• Provider and community referrals

Engagement

• Face-to-face meetings at least quarterly with ongoing regular telephonic contact

• Assessment of member’s needs

• Planning, facilitation, intervention, and advocacy to meet identified needs

• Ongoing monitoring and evaluation of the case management plan

Outcomes

• Clinical• Financi

al• Satisfac

tion• Quality

of Life

•Identification Mechanisms:1. Referrals from CareSource’s Medical

Management Department

2. Referrals from CareSource’s data department based on electronic Predictive Risk Modeling – John Hopkins University ACG software combines medical, behavioral health, and pharmacy claims, creating clinically relevant categories as well as risk scores for our members

3. Referrals from provider & community partners who work with members in crisis on a daily basis, in real-time

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Who Are High Risk Members?

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High Risk Care Management

Predictive Modeling

Demographic

Utilization

Diagnosis

Cost

High Risk Criteria Greater than four chronic co-morbidities (such as: DM, CAD, HTN, CKD, COPD, Asthma, SCD, HIV) Behavioral health diagnosis including Schizophrenia, Major Depression, Bipolar Disorder A sudden disability (e.g., stroke, head injury, spinal cord injury, paraplegia) Hospital re-admit within 90 days

Multiple avoidable ER visits in the past 6 months

Greater than 12 prescriptions or high cost drugs

High Risk pregnancy

Unable to access PCP/unable to keep or get to preventive visits Limited or no caregiver resource

NICU admission > 7 days27

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Focus of High Risk Case ManagementMember-driven case management process

Help members regain optimum health and function

Promote adherence with prescribed treatment plan

Self-management education, preventive care support

Improving health outcomes and health care costsPartnership with providers to maximizes benefits of primary care and medical home

• Care Coordination• Health Promotion• Advocacy & Access• Outreach• Linkage for Basic

Needs• Collaboration

What Services Does CareSource’s High Risk Case Management Program Provide?

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Care CoordinationThe Primary Service of High Risk Case Management.Facilitate care across health, social and enabling services through:• Comprehensive health assessments: bio,

psycho, social, spiritual• Individualized care plans based on

Member’s strength, needs, and preferences

• Identification and inclusion of all providers• Provision of clinical and service

summaries, such as the Provider Portal• Proactive communication with all

providers, members and families

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Health PromotionSkill & asset building to help members mange their illness and maximize wellness through:

• Developing understanding about their conditions and importance of treatment/medication adherence

• Utilizing available treatments and pathways to health

• Building skills and resources for self-management and wellness

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Advocacy and Access

Ensuring members have the services and resources they need across:• Healthcare providers• Social service systems• Enabling services, such as

transportation and peer support

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OutreachCommunity based work, to engage members in healthcare, including:• Serving members “where they

are,” based on their preferences• Assertive engagement,

including home and provider visits

• Identifying health and support resources

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Linkage for Basic Needs

Linking members and families to resources that are prerequisites to healthcare:• Food• Clothing• Shelter

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Collaboration CareSource Members + Family

CareSourceRN Case Manager, Social Worker, Behavior Health,

Patient Navigator, Disease Management, Pharmacy, Care Transitions

Primary Care Physician Community Services

Community Behavior HealthYMCA

CareSource’s Provider Portal:• Confirm member’s eligibility• Review coordination of benefit information• Submit prior authorizations• Review care plans• Make referrals for care or disease

management• Review individual member or practice HEDIS

measures• Review the Clinical Practice Registry• Review the Member Profile

Collaboration (cont.)

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HRCM Program Evaluation• Quality

• HEDIS• Condition Specific

• Satisfaction• Survey• Grievances

• Cost• Overall Medicaid costs • ED utilization rates• Inpatient rate

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BH Strategy: Enhance our clinical programs

• Embed BH Specialist into all CM teams• BH Coordinator role for BH Specialist staff • Ongoing training and learning for all clinical staff • Deploy “BH Pathways” for all member facing

staff• Ensure CM, MM, & Care Transitions

collaboration• Provide member self-management tools

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BH Strategy: Web Based Tools

• Provider Portal

• Health Home Portal

• Snapshots

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BH Strategy: Improve provider services

Access• Availability of BH in primary care• Telehealth• Fill gaps in CMHC care

Care Coordination Resources for BH Providers• Integrate staff• BH Provider data sharing solutions • Medication interventions • Provider and stakeholder education

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BH Strategy: Advocacy

Lead local, state and federal advocacy• Initiatives• Regulatory alignment• Plan Alignment

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We want to collaborate with you!

• CareSource Programs

• Tools and Resources

• Specific Partnerships

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We want to collaborate with you!

CareSource Programs

• Participate with our shared members in our programs

• Work with our community based care management!

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Collaborations

Tools and Resources• Member Profile

• Clinical Practice Registry

• Care coordination • Inpatient notification system for BH

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CollaborationCareSource Provider

Portal

(right) Clinical Practice Registry

(below) Case Management Referral

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We want to collaborate with you!

Specific Partnerships

We want to work with you to help members…

Do you …• Know your Member’s payers?• Understand OH Medicaid programs’

coverage?

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Summary• CareSource thrives on partnerships

‒ Open to creating new ways to partner

• More Behavioral Health services not less‒ BH is essential to overall health wellness and

community tenure

• ContactJonas Thom, M.A., PCC-S Vice President of Community Programs

‒ jonas.thom@caresource.com‒ 937-531-2137

Questions? Contact Information:

Timia DelPrete-Brown Timia.DelPrete-Brown@caresource.com

(216) 896-8205

Jonas ThomJonas.Thom@caresource.com

(937) 531-2137

Terry Jones, Director of Behavioral Health Terry.Jones@caresource.com

(937) 531-2401

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Mission: The CareSource Heartbeat

Making a difference in the lives of underserved people by improving their

health care

Vision CareSource Management Group will be an

innovative leader in the management of quality public sector health care programs

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