Expanding Managed Care: Integrating Medical Care and Supportive Services

Jessica Briefer French Medicaid Health Plans of America

October 27, 2014

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Managed Care and Special Populations 8 states have begun enrollment, some as early as 2013

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Managed Care and Special Populations

• States with Managed LTSS programs doubled from 8-18 between 2004 and 2014*

• Number of persons served through Managed LTSS programs increased from 105,000 to 389,000** as of 2012

*Center for Health Care Strategies *MACPAC June 2014

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Case Studies Project • Case study of sites providing integrated care to

dual eligible population • Goal to understand current state of

– Goal setting and assessment for person-centered care planning

– Information sharing of assessment and care plans (integration)

• 3-day site visit to 8 sites (complete) • 4-day site visit to 4 sites (underway)

Funded by the John A Hartford Foundation and The SCAN Foundation

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Model for Evaluating Quality

Beneficiary Engagement & Rights

Population Management & Health Information Technology

Quality Improvement Systems

Screening & Assessment

Individualized Shared

Care Plan

Coordinated Service Delivery

Healthy People Healthy

Communities

Better Care

Affordable Care

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Interdisciplinary Team Structure

Images from: TRUVEN Health Analytics

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Case Studies: What is a Care Plan?

• In theory: person-centered, goal-based, comprehensive, interdisciplinary, shared, living plan for addressing quality of life goals impacted by medical, functional and social needs.

• More often in reality: service-centered, problem-based plan for providing long term services and supports and care coordination to address medical, functional and social needs.

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Case Studies Findings: Integration

“Integrated Care” is a misnomer • Care continues to be delivered in silos

– Medical – Behavioral – Supportive services

• Information sharing impeded – Language and culture of different disciplines – Technology

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Current State Siloed, redundant care plans, that are service oriented

Single, shared care plan that addresses whole person needs

Unclear what population-level outcomes organizations can fairly be held accountable for

Individualized outcome measure targets as performance measures

Where we want to be Integrated Care

Unclear where accountability lies resulting in multiple layers of “care coordination”

Clear and fair accountability without adding additional layers

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Information Sharing Information Full care plan, summary or request for action

Method Fax, phone, in person; not much electronic

PCP Role

Receives info, requests for action in health plans; more integrated in provider orgs

Longitudinal view varies by type of organization

• Provider sites: population management • Health plans: predictive modeling • Care manager relationship constant over

time

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Integration Approaches Observed

• Personal relationships • Care management team of RN, SW • Care management embedded in PCMH • Care manager accompanies individual to

medical appointments • Real or virtual case conferences

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Assessment, Goal Setting, & Care Planning Process

Identified Needs

Individual

Stated Goals

Goals of Care

In Home Assessment

Interventions

Care Plan

Outcomes

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Case Studies: Documented Goals • Goals reflect services planned

– “Wants to continue with established services including Homemaker, Lifeline, supplies and adult day care.”

• Goals reflect self-care and provider interventions – “Member will maintain health with maintenance

exams and preventative screens” • Goals address immediate needs such as post-acute

care – “Support participant in returning to maximal level of

function and return to safe community living with (organization) and family support.”

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Current State

• Not documented • Automated • Assumed • Dictated or suggested

by care manager • Unclear how related to

outcomes that are important to the individual

Where we want to be Goals

Variation in “person-centered goals”

Use validated PROMs to assess wellbeing, set goals, and track goal achievement • Specific • Measureable • Achievable • Relevant and time-bound • Negotiated • Individualized • Directly and clearly related

to outcomes important to individual

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Patient “I just want to get back with my daughter”

Care Plan • Reduce psychiatric admissions • Keep member in appropriate housing • Client will take her injectable

medication to treat her xxx. • Member will remain free of asthma

attack and understand what to do if she has one

• Member will not exceed BP of xx/yy and will contact PCP if over this parameter

• Member will choose PCP, make and keep appointments

Translating Patient Desire to Care Plan

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Patient: “Lord give me the power to walk”

Care Plan • Open sites to heal • Ensure safe transition home with LP and

family support • Participant will receive acute medical

care in order to optimize health and return to least restrictive environment (generic hospital goal)

• Provide safe environment throughout weekend

• Provide appropriate hoyer lift and sling for home use

Translating Patient Desire to Care Plan

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Case Studies: Key Takeaways

• Lots of variation in practice - no one size fits all • Lots of information is documented –

infrastructure and relationships necessary for sharing and using information are insufficient

• Easy to measure presence, timeliness, contents of care plans; harder to measure quality, link to person’s goals

• Person-centered care plan goal means different things to different stakeholders

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Where Do We Go Next?

• Collaborative learning to determine what works best

• Structure and process measures are important foundation and roadmap, but insufficient

• Need to manage care against meaningful outcome measures

• Outcome measures are needed, but challenging – Fairness in use for accountability

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What Are the Relevant Outcomes?

• Competing health problems, needs • Improvement may not be expected • Measures that work for general

populations are not best for people with complex needs

• Can we individualize care in order to – address individual’s goals and increase their

engagement – improve care system outcomes (triple aim)

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Questions, Comments?

Jessica Briefer French Senior Research Scientist, NCQA French@ncqa.org 202-955-1776