San DiegoLong Term Care Integration Project

Planning Committee PresentationSeptember 10, 2003

Community Planning Process

From 50 to 400+ key stakeholders over past 4 years: 10,000+ 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

Rodger G. Lum, Ph.D, 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.

GovernanceWorkgroup

Case Management Workgroup

Finance/DataWorkgroup

Information TechnologyWorkgroup

Internet• -Facilitates

communication• -Provides broad public

education

Pamela B. Smith, Project DirectorAging & Independence Services

Lead County Agency

Quality AssuranceWorkgroup

Develop a model thatsupports integration acrossthe continuum of care to ensureeasy access to care & services.

Determine the financialfeasibility of the proposedLTCIP for San Diego County.

Determine consumerprotection & qualityassurance standards &requirement for the LTCIP.

Identify the information &technology requirementsneeded to support a LTCIdelivery system.

Develop a recommendationfor the governance structurefor the implementation phaseof the LTCIP.

Workforce IssuesWorkgroup

Increase the number of trained providers across the long term care continuum workforce, with an emphasis on quality care.

Long Term Care Integration Project Organizational Chart & Decision Tree

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

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

Legislative Authority

AB 1040 in 1995 (revised in 1998) State Office of LTC:

– provides planning $$– provides “Center” resources– provides liaison with other state programs– approves local activity toward LTCI– will assist in procuring federal waivers

Why change?

To align incentives for optimum care across the continuum

To impact quality of life for aged and disabled, especially high cost users

To respond to demographics that require Medicare to respond to chronic care needs

To shift focus to consumer and outcomes To respond to Olmstead Decision

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

Client Referral Patterns

CUSTOMER ACCESS with LTCIP

Customer At Home/Community

Care Manager w/ Network of Care

IncomeAsst.

SeniorCntr.

In-homecare

HICAP

MedicalClinic

BloodPressure

Cks

ShoppingAsst. rehab

Transp.Escort

housingHealth Care

Intake Worker InformationProvided

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

HSD Currently Does NOT…

Tailor the program for chronic care or aged and disabled persons

Provide “wraparound” services Provide chronic care management on a

population basis Receive adequate reimbursement for

chronic care Have much info on “duals”

Where are we now?

Last year, BOS: “come back with 3 options” next Spring

Since then: Dr. Mark Meiners assists w/strategies development:– Network of Care– Physician Strategy – HSD Health Plan/Pilot Projects

Network of Care

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

To develop “continuous quality improvement” program

Measure behavior changes of providers and consumers

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

Health Plan Pilots

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

stakeholders agree– Healthy San Diego Health Plans to develop

pilot with consultant resources

New Parallel Initiatives

Medicare reform: Drugs and Duals CMS “chronic care” M+C demos SHMOs and “special needs” plans AB 43 in California and LTCIP pilot Medi-Cal and disease management PACE in San Diego Mass. Senior Care Organization

Consultant Team for HP Strategy

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

Dave Ogden, Milliman USA Charles Birmingham and Karin Kalk,

Health Plan Consultants LTCIP Staff and Stakeholders

Consultant Proposal Long Range

95,000 have 2 choices– Physician Strategy

• MD incentives• Support for chronic care• Across

Medicare/Medicaid– HSD+

• NF & “certifiable” duals• Aged, then younger• Then all HSD ABDs• Then all ABDs

Consultant Proposal Funding

Who?– HSD plans that meet

requirements– With or without

current Medicare participation

– May subcontract for LTC

– Care management must be overarching

Medi-Cal– Acute, LTC, IHSS,

1915(c) waiver Medicare

– Waiver to allow HSD to serve duals w/cap

– “demo” status to add “frailty adjuster”

Actuarial Consultant “Scenarios”

Scenario A– Initial, moderately managed utilization– 16% of Medicare payment available for

admin, profit, HCBC Scenario B

– More developed, managed utilization– 22% of Medicare payment available for

admin, profit, HCBC

Key Program Components

Common entry point: intake, risk screens, and needs assessment

Care plan development: electronic assessment and C-E triggers

Care coordination standards: contracted to gain CQI via team care approach

Common data: risk assessment, point of service PDA, data warehouse

Network development support: HCBS focus

Proposal issues already identified

Physician Strategy diminishes HSD plans’ potential provider network capacity

Younger disabled do not appear to be financially “attractive”

What to do re: mental health?

Next Steps

Health Plan and Stakeholder input on Consultant Proposal

Develop Administrative Action Plan (Jan. ’04)– NOC (AoA/CMS funding?!)– Physician Strategy (CA Endowment $$)– Health Plan Pilots: HSD & AB 43

Stakeholder consensus (Feb. ’04) Board of Supervisors approval (Mar. ’04) Examine new federal initiatives

How to influence planning?

Get on LTCIP mailing list for updates

Log onto website for background & info: www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc

Call or e-mail input/ideas: 858-495-5428 or evalyn.greb@sdcounty.ca.gov