Caveat Vendor:

Lessons Learned from Contracting with Healthcare Entities

2015 Aging in America Conference

June Simmons, CEO, Partners in Care FoundationSandy Atkins, VP, Strategic Initiatives

Amanda Daninger, Project Manager, Networks

Thanks to our funders for helping us be trailblazers

With gratitude to theJohn A. Hartford Foundation

& Archstone Foundation

Partners in Care FoundationChanging the Shape of Healthcare

Partners in Care Foundation serves as a catalyst for shaping a new vision of healthcare

by partnering with organizations, families and community leaders

in the work of changing healthcare systems, changing communities and changing lives—

focusing on home and community care.Values: Collaboration, Innovation, Impact

Partners in Care FoundationChanging the shape of health care

• 3 CMS CCTP Care Transitions programs producing exceptional results

• Innovator – Creator of HomeMeds & Healthy Moves – both highest-level evidence-based programs

• Pioneer in forming CBO networks to provide person-centered community-based services under contract to health plans, physician groups, & health systems

• Trailblazer in navigating the duals demonstration from Medicaid waiver to health plan contracts

The place for social services in health care

CBOs are essential to providing person-centered care

Why change business models and contract with health care entities?

• Seize time of dramatic change – integrate healthcare and social services – expand by moving health dollars to home and community services

under health reform• Foundation funding has time-limits

– Use for innovation, not operations• Waiver to be absorbed by Medicaid MCOs

– 40% of budget before healthcare contracting– 20% of budget after healthcare contracting

• OAA faces expanding identified need – health payers need to participate

• Healthcare dollars here to stay…if positive ROI

Health Care’s Blind SideRWJF Survey of 1,000 PCPs:• 80% “not confident in their capacity to address their

patients’ social needs.” • 86% said “unmet social needs are leading directly to worse

health.”• 76% wish the healthcare system would cover cost of

connecting patients to services to meet health-related social needs.

• 1 of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance. Health Care’s BLIND SIDE - The Overlooked Connection between Social Needs and Good Health, Robert Wood Johnson

Foundation, December 2011, http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795

Health Care + Social Services = Better Health, Lower Costs!

• Address social determinants of health– Personal choices in everyday life– Isolation, family structure/issues, caregiver needs– Environment – home safety, neighborhood– Economics – affordability, access

• Social Service Agencies Have Advantages– Time to probe, trust, different authority– Cultural/linguistic competence– Lower cost staff & infrastructure– High impact evidence-based programs

Door Openers: Meds, Falls, QualityResults of our interventions appeal to healthcare:– HomeMedsSM addresses multiple quality/Star domains

• High-risk medications• Hypertension control• Pain control/assessment

– Care Transitions with medication reconciliation – required by NCQA for health plans

– Fall risk management: % of Medicare members 65+ who fell or had problems with balance or walking in past 12 mo. who received fall risk intervention

– Providing person-centered care improves client satisfaction and (we hope) member retention.

"No risk factor for falls is as potentially preventable or reversible as medication use.

(Leipzig, 1999)

3 Service lines to be offered

Evidence-based Self-Management

Independent w/ chronic condition

Stanford Chronic Disease Self-Management

(Online, Diabetes, Pain, Spanish)

Matter of Balance, etc.

Short-term In-Home Services

At risk for deterioration & high utilization

HomeMedsCare transition

coachingIn-home psychosocial

evaluationService coordination

Long-term Services & Supports

Frail/disabled

Service coordinationPurchase of

services (meals, respite, transport,

chores)

Value Proposition: CBOs & Triple Aim

• ED• IP

COST• Pain• Falls

HEALTH

• Needs Met• Member

Retention

QUALITY

Care Transitions Coaching

HomeMedsPlus

Stanford Self-Management Workshops

HomeMedsA Matter of BalanceHealthy Moves

Complex Community Care Management

MealsHome visitTransportation

CBO Network Service Lines – Value Proposition: Who Pays and Who Saves?

Prevention: MA Plans; Capitated Med Groups

EOL

LTSS &CaregiverSupport

Care TransitionsHomeMeds/HomeSafety Assessment

EB Self-Management:CDSMP/DSMP; MOB; Healthy IDEAS; EnhanceFitness; PEARLS; Fit & Strong

Senior Center – meals, classes, exercise, socialization

ED/Hosp: Capitated Providers/Plans Readmission penalties: Hospitals

Chronic Disease Management:Duals Plans; MA SNP

25% of all Medicare is Last Year of Life: Duals Plans; Medicare Advantage SNP; ACO/MSSP

Nursing Home Diversion for Duals Plans

Results for Our Programs

• LTSS waiver program for duals – Keeps nursing-home eligible seniors at home for an average

of 5 years!• Cost? $357/month vs. $3,000+ for SNF

• Care Transitions Coaching & Social Services– At UCLA, cut readmissions by more than half!

• 10.1% readmission rate vs. 27.1% for those who met criteria but did not receive intervention

• HomeMedsPlus– Home visit, med rec, pharmacist, psychosocial/ functional

assessment, home safety evaluation• In physician group post hospital – 13% lower rate of ED use &

22% lower rate of readmission w/in 30 days• Discovered medication-related problems in 63% per

pharmacist…AFTER hospital medication reconciliation

Our Contracts• Care Transitions Coaching:

– CMS, Blue Shield, Molina• HomeMedsPlus – 30, 60 or 90 days of care coordination:

– UCLA Health System, California Health & Wellness (Centene), Desert Oasis/Heritage, Blue Shield

• Evidence-based self-management programs– Blue Shield (giving us contact info for thousands; we engage & enroll)

• LTSS – Waiver continuation under duals demonstration– Molina, L.A. Care, Health Net, CareMore/Anthem BC, Care1st

• Others– Adult Day Health eligibility determination – RN face-to-face assessment,

Health Net, Care1st, L.A. Care– Safe discharge for mental health/dual diagnosis/homeless after medical

admission (Prospect)• Contracts across 6 Southern California counties, extending into

Northern California – engaging CBO network members

HomeMeds℠ - Anchor for successful contracting

• HomeMeds℠ is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety

• Translated into healthcare lingo we’re doing a home medication review (or reconciliation) and pharmacist intervention

• Focuses on adverse effects (falls, confusion, dizziness, vitals) … then determines if medications may be part of the cause.

• Targets problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response.

• Cost-effective use of geriatric pharmacist for complex problems

HomeMeds℠ Evidence-Based Recognition• AoA recognition as an evidence-based prevention program –

Highest Level of Evidence

• ACL Aging & Disability Registry of Evidence-based Programs and Practices

• Quality of research: 3.2/4• Readiness for dissemination: 4/4

• US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange

• Strong evidence ratinghttp://www.innovations.ahrq.gov/content.aspx?id=2841

HomeMeds Improves Medication SafetyHomeMeds is a TARGETED intervention addressing a limited group of medication related problems identified by national expert consensus panel ¹1. Targets problems that can be identified and resolved in the home.2. Chosen to produce positive response by prescribers3. Minimize “alert overload:” based on signs/symptoms and adverse effects.

Resolving these medication-related problems: Unnecessary therapeutic duplication Use of psychotropic drugs in adults with a reported recent fall

and/or confusion Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at

risk of peptic ulcer/gastrointestinal bleeding Cardiovascular medication problems -High BP, low pulse, orthostasis

and low systolic BP

¹A model for improving medication use in home health care patients . Brown, N. J., Griffin, M. R., Ray, W. A., Meredith, S., Beers, M. H., Marren, J., Robles, M., Stergachis, A., Wood, A. J., & Avorn, J. (1998). Journal of the American Pharmaceutical Association, 38 (6), 696-702.

HomeMedsPlus• HomeMeds – medication inventory, assessment for adherence

and other medication-related problems, pharmacist review/recommendation

• Plus:– Psychosocial & functional assessment – ADLs, PHQ9, etc.– Fall Risk/Home Safety evaluation

• Problem list & service plan• Care coordination for 30, 60 or 90 days

– Depends on plan/group and their CM program• For people returning home from hospital and targeted

moderate to high-risk people

Facing the future togetherNetworks of CBOs will enable all boats to rise together and give us scale to compete successfully and regionally in post-

ACA markets

New Environment=Opportunities & Risks for CBOs and for Medicine

Opportunities:ACA focus on Triple Aim: Social services address

Cost, Quality, Satisfaction & Member Retention

Contracts with Plans & Providers give us Greater

Reach, More impact, Sustainability

RisksHealth Plans Try to Build

what We Already DoLoss of government funding w/o new

$ sourcesDemise of CBO Sector

Theory behind the Network• IF CBOs join together to present a unified,

multiregional contracting entity to regional, statewide or multistate healthcare organizations

• AND they can meet the quality, volume, confidentiality, geographic coverage and information needs of healthcare

• AND they can demonstrate their value in terms of the Triple Aim

• AND they are competitively priced

• THEN they will win contracts with healthcare entities and perform well

Why Focus on Integrated Networks for Medical Care and Social Services?

• Improve health for adults with chronic conditions through comprehensive, coordinated, and continuous expert and evidence-based services

• Add supportive social services to medical care– Improve health outcomes & reduce cost of medical care

• ACA and Duals plans opportunity for expanded LTSS• Government/OAA funding threatened.

– Opportunity to compensate for this through health plans, which are large, often multi-regional and multi-state

Threats to our Role

• Build vs. Buy– Medicine tends to want to own everything – do

this themselves– National for-profits see a large market and have

distinctive assets – capital, IT and sales– We need to bring our distinctive assets and

compete against some of theirs

Why belong to a network?• Contracting is expensive

– Legal fees – one contract $40,000+• Contracting is time consuming – multiple meetings

every week over 9 months – ~2,000 hours of senior/ executive team time for one contract– Build the relationship – prepare materials, business case– Negotiate the contract – pricing, terms, requirements– Roll out the program

• Develop workflows• Policies & procedures• Hire & train staff

– Reporting & evaluation

More Reasons to Belong Competition – Large national companies like APS promise

efficient service, unified IT, analytics, quality assurance

Medical Loss Ratio – BillingHealth Plans must spend 85% on clinical care & quality

No more pilots under administrative budgetTo be clinical, you need license &/or accreditation

Accreditation is costly ($33,000+) Requires huge effort…better through a single entity. May be required for contracting with health plans other than Medi-Cal,

especially MedicareLicense: Shared cost for licensed supervisionMedicare Provider # Difficult

Huge investment in change for healthcare

• Every meeting with us…was a meeting for them• Lawyers for them, too• These are disruptive innovations/changes for

healthcare• Dept. Managed Care has to approve every contract• Delegation issues with NCQA accreditationMany healthcare entities are regional or statewide• Doing this with multiple agencies would be prohibitive• Investment will reap an integrated statewide network

and coordinated delivery system

Network Functions 1: Meet Health Plan Due Diligence Requirements

• Credential network members to assure compliance with contract terms– HIPAA/HITECH security– IT Systems for data exchange– Insurance coverage and range (e.g. cyber)– Staff – drug testing, background check, TB test, etc.– Medical loss ratio (MLR)– License/certification/accreditation

Network Functions 2: Quality Assurance & MLR

• Primary organization earns accreditation • Ensure consistent delivery of service• Fidelity to evidence-based models• Performance data• Supervision by licensed personnel (e.g., LCSW,

RD, RN)• R & D – evaluation, analytics, dashboards

Network Functions 3: Business Office

• Shared sales & marketing• Negotiate and hold contracts• Training and assurance of consistent services• Contact center/communications systems• Policies/procedures – HIPAA/HITECH• Liaison to plan to hold relationship/evolve services• Billing & service authorization• Maintain IT infrastructure• Legal support

Asserting the value of your care by the quality of your work

CBOs can claim the value of the services provided with quality accreditation.

Why Pursue Accreditation?

• Federal stipulations – The ACA and the Medical Loss Ratio

• State regulations– California Department of Managed Health Care

• Health Plan requirements– Delegation & their own Accreditation

• To prove that we are worthy of trust and can meet rigorous requirements

• Good Housekeeping Seal of Approval – NCQA is “Gold Standard”

NCQA CM Accreditation• Health Plans Must Assess/Evaluate Members’:

– Clinical hx & medications– ADLs– Cognitive function– Psychosocial issues– Health behaviors– Life-planning activities– Cultural/linguistic needs, preferences, limitations– Visual/hearing needs, preferences, limitations– Caregiver resources/involvement– Available benefits– Community resources

NCQA Application Process• Policies/procedures for everything we do

– Documentation, documentation, documentation• Meet to discuss each standard

– Interpret language & translate to CBO• Board review• In 6 weeks between submitting paperwork & site visit

– Prepare staff for the visit• Standard is documentation + implementation

• Respond to the executive committee’s review and recommendations

• Receive the determination from the Review Oversight Committee.

• Implement policies/procedures across the organization and network in preparation for next evaluation (2 years)

Challenges• Written with a health plan in mind

– Vocabulary – e.g., what is “clinical”– Population health management

• Interpretation– Accrediting organization vs. program– Categories – complex case, transitional care, high-risk,

organizational program• Commitment

– Time for staff work• Cost ~$65,000

– NCQA fee ($33,000)– Consultant to help us ($30,000+)

Benefits• Quality Accreditation is a language of assurance in health

care.– Health plans and physician groups will be more receptive to our

work.• When Partners is accredited, our network partners may also

benefit without the costly burden of applying themselves.– Depends on the structure of the network – only CM provider

organizations can be accredited, e.g., MSO can’t be accredited unless they do CM

• Credibility• Protects the accreditation &/or state managed care license

of the healthcare organizations who contract with us

Lessons Learned

Best practices and caveats for CBOs contracting with

health plans and physician groups

Caveat Vendor• Contracting takes time• Time from initial meeting to signing contract can be >1 year.• Pricing is vital and complex

• Communication matters • Bi-lingual/bi-cultural medical/social• Handoff from Plan’s contracting team to implementation team lost

continuity – need to keep educating on value of HCBS;• Discuss IT needs and solutions before implementing the contract;

• Partnerships matter• Integration with Plan CMs view CBO as partners referrals.

• Volume = sustainability• Getting contract doesn’t guarantee volume; ONGOING WORK!• Need a way to cover up-front investment – setting up systems,

legal expense, training staff -----Start-up capital

Best Practices• You cannot over-prepare!• Playbook define roles/responsibilities for implementation

• Emphasize the value of communication• Insist on ongoing training with Plan’s case managers• IT that enables CMs to log in and check status of members

• Fail fast!• Mistakes will be made; the sooner you learn from them and

move forward, the better off you’ll be• Underscore your value!

• Value proposition – “no margin/no mission” for both - $$• Quality Accreditation of community-based care coordination

provides common language between cultures• IT that automatically measures effectiveness, staff performance.

Metrics Learning Quality Improvement Keeping Contracts!!

% of referrals who previously received intervention Highest risk – study this!

% Ineligible for InterventionUse data to refine targeting methods – less work for all

% RefusedLearn who, how, when, why to reach more people

% Unable to reachAnalyze by time of day, reason, new approaches

No outputs = no outcomes!

Where to focus – root causesCoach1 # Coach1 % Coach2 # Coach2 %

Referrals 100 100Room visits 89 89% 75 75%Calls completed 78 78% 50 50%Refusals 28 36%* 10 20%*Home visits 50 64%* 40 80%*

What is the story? What does it mean? Turning data into action…• Coach 1 calls all 100 referrals; calls 4 times at different hours• Coach 2 calls only those visited and calls 3 times during business hours –

but has a lower refusal rate• Coach 1 can teach coach 2 how to make more connections• Coach 2 can teach coach 1 how to get a higher acceptance rate

*Denominator is Calls Completed

Advice on Price• Basic pricing model for usual services

– Formulas recalculate by changing assumptions• Role of plan CM vs. CBO staff for implementing services• Duration (one-time, 30 days, 60 days, 90 days, TDDUP)• # participants in CDSMP

• Don’t settle on price until you see final terms of contract - they often add as they go

• Don’t settle on price until you know the volume– Go for some way to cover start-up costs– Volume-based pricing (more volume=lower $)– Other incentives for more referrals– Data system – criteria for automatic referrals

• Include cost of managing network

Contract requirements…surprise!• No data on laptops or mobile devices• Must have data disaster recovery plan (backup & restore)

– Tested annually and test results submitted to plan• “Physical Security & Environmental Controls”

– Limit access to those who need it; secure environment• Must provide documented data security plan including

diagrams, info architecture, risk assessment, policies• Annual security audit & report provided to Plan• Insurance – Privacy Liability and Network Security

– Higher limits - $3 million/$5 million

More requirements• Same-day documentation of every attempt to contact

member (Imagine this without IT!)– Date, time, notes, plan

• Document supervision/monitoring by LCSW• Provide access for Plan to internal record-keeping systems

related to Plan members• Provide monthly summary of services delivered (and not

delivered…with explanation)• Maintain data system compatible with Plan’s and capable of

data exchange• Secure File Transfer Protocol (SFTP) & Secure Email required

Prove Value? Targeting required!• Tiers of need & tiers of service• Risk for 911/ED, hospitalization, readmission, institutionalization

– Medications – multiple chronic conditions– Caregiver issues or living alone– Health literacy – understanding illness, problems & orders– Activation – Adherence – Access– Cognitive impairment

• Root cause analysis or validated risk assessment tool– E.G., LACE for readmission

• Length of stay• Acuity• Comorbidity (Charlson)• ED Use

IT – Absolutely Required• Moving from hundreds of waiver clients to thousands • Screening criteria – less reliance on humans for referrals

– Ideal: connect directly to EHRs• Enable population health management

– Plan providing 1000’s of names – we sort, process, call, engage• Manage workflow for short-term work and higher volume • Secure communication: internal & with new payers• Analytics for external reporting and internal QI

– Demonstrate outcomes• Billing/reconciling payments – with multiple contracts/rates/scopes• Partnership with Loopback Analytics to adapt to new work

Winning Contracts Isn’t Enough

Referrals

Acceptance

Completion

Healthcare Changes• IT supports

targeting/referral• Programming to

support data exchange• Champions at all

levels• Workflow changes• Patient/member

motivation• Share outcomes data• Respect CBO

expertise

CBO Changes:• Better IT systems• Better IT security• More insurance• Accreditation• Provider #• Motivate health

plan CMs to refer & work with us• Workflow• Understand health

plan regulations• Motivate patients &

participants• Address barriers for

patients

Volume is a prerequisite for sustainability

New Paths for CBOs• Outcomes oriented – focus on impact & value• Data-driven– Requires sophisticated IT systems for analytics &

interoperability – Determine appropriate

• Risk taking, learning organization– Learn from inevitable mistakes– Fast feedback loop – review data weekly & take

action to correct

Usual work, new standards• Our traditional services can affect outcomes for

health plans, hospitals, ACOs and provider groups• We have to do it better & faster– New Culture: How high?!! Accountability. Quality.

• Health plans and physician groups expect us to follow consistent quality standards.

• We have to measure & improve constantly– Data – We MUST require contracting partners to share

timely data and information so we can improve…and demonstrate outcomes!

Questions?

Contact

• Partners in Care Foundation– June Simmons, CEO• 818.837.3775• jsimmons@picf.org

– Sandy Atkins, VP, Strategic Initiatives• 818.632.3544• satkins@picf.org

– www.picf.org; www.HomeMeds.org