Oregon Health Plan Care Coordination Program (OHPCC)

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Christiana Knight
6 years ago
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Jeffrey McWilliams, MD, Medical Director KEPRO Oregon

1 Oregon Health Plan Care Coordination Program (OHPCC) John DiPalma, Executive Director KEPRO Oregon Dr. Jeffrey McWilliams, MD, Medical Director KEPRO Oregon Michael Wolf, Vice President of Government Relations KEPRO

2 The Bottom Line Key takeaways from our discussion today: Oregon s Open Card/Fee-for-Service Program serves as the backstop for the Oregon Health Plan (OHP) and brings added value to the state s efforts to transform the health care system. The program, administered by KEPRO, complements the coordinated care model by ensuring that no OHP member falls out of coverage. It s not Open Card vs. CCOs it s a partnership, one that ensures that all Oregonians are receiving the right care, at the right time and in the right setting. KEPRO s care coordination has saved Oregon $85 Million over the past 6 years. 2

KEPRO Overview Since 1985, KEPRO has helped more than 20 million members live healthier lives through clinical expertise, integrity and

We offer innovative and outcomes-focused solutions to reduce the unnecessary use of health care resources and optimize the quality of

We are headquartered in Pennsylvania and have offices in California, Florida, Illinois, Maine, Maryland, Massachusetts, Minnesota, Ohio,

3 KEPRO Overview Since 1985, KEPRO has helped more than 20 million members live healthier lives through clinical expertise, integrity and compassion. We are the nation s largest CMS-designated quality improvement and care management organization. We offer innovative and outcomes-focused solutions to reduce the unnecessary use of health care resources and optimize the quality of care for public and commercial clients. We are headquartered in Pennsylvania and have offices in California, Florida, Illinois, Maine, Maryland, Massachusetts, Minnesota, Ohio, Oklahoma, Oregon, South Carolina, Tennessee, Virginia, Wisconsin and West Virginia. We are firmly committed to locally-managed operations in the states we serve. Our Oregon office is located in Tualatin with case workers and care managers located around the state. 3

4 OHPCC Overview Since 2010, KEPRO has provided Care Coordination Services for the Open Card/Fee- For-Service members of the Oregon Health Plan (OHP). OHPCC is a cost-neutral service provided to OHP Open Card and Dual Eligible members to coordinate their individual health care needs. We use a collaborative process that facilitates treatment plans and ensures appropriate medical care is provided to the individual to promote quality and cost-effective outcomes. We coordinate care for approximately 12 percent of the OHP population (approx. 120,000 members per month). Our case managers coordinate medical, dental and behavioral care across the continuum to provide integrated whole-person care to our members. In July 2016, our scope of work was expanded to include behavioral health screenings under the 1915(i) Waiver Program. 4

5 OHPCC Overview General Characteristics of the OHPCC Program Any OHP member not enrolled in a CCO qualifies for the OHPCC, including: Dual-eligible (Medicare and Medicaid) members must opt-in to join a CCO. American Indian & Alaska Natives have the ability to join and leave a CCO as they choose. Medically fragile children who have special needs. Members covered under third party liability insurance. Continuity of care if no reasonable alternatives are available. 5

6 OHPCC Geography Enrolled Members in OHPCC Per County 6

7 OHPCC: Care Coordination Provide Health Coaches to Open Card members to help them manage their condition, illness or disease. Provide a 24-hour Nurse Advice Line for all of our members to call anytime to get help! Offer care coordination services for all Open Card members in the state of Oregon. We analyze the claims data received from the State of Oregon and identify the highest acuity members via our Percolator Software. We conduct outreach to members, do a thorough assessment of their health, living situation, and support system in order to guide them to improved health. We provide a Plan of Care consistent with their provider s care. We work with members on medication compliance, exercise, diet, making appointments, education and more. We provide resource assistance to members in need of community or state assistance programs for such things as transportation, help paying household utilities or locating a doctor or specialist. 7

8 Care Coordination Strategies Strategy In Home Medication Reconciliation Referrals to APD Case Manager Services Transitions of Care Fall Prevention Integration of APD Assessment Data Nursing Home Diversion Activities Serious and Persistent Mental Illness Diagnosis Specific Care e.g. Diabetes Headline Top reason for readmission is improper use of medications. CB RNs visiting members in home to ensure. Our RNs have the capability to refer members to Case Managers at APD so that they can receive services based on Service Priority Level (1-13). Like FFS, the RNs both telephonic and CB, will coordinate care with discharge planners and providers to coordinate optimum placement. All RNs will be trained on Fall Prevention and will be able to do a full fall prevention check list with members to minimize risks. Oregon Access is the APD system that tracks members receiving services offered through the state. We coordinate this data with C3 to maximize coordination. Whether we are working with a member to leave a nursing facility or diverting a member to a more optimum facility, the goal is to minimize costs. Behavioral Health challenges are persistent in this population; medical care and behavior care will be closely coordinated (diseases, suicides, etc.). Fundamental Disease Specific Management must continue to be a foundation on which this program is built. 8

OHPCC Outcomes We achieve triple aim in Oregon with better outcomes, better experiences of care and lower costs, saving the state $85 million for the first six program years and a 3.1:1 ROI.

9 OHPCC Outcomes We achieve triple aim in Oregon with better outcomes, better experiences of care and lower costs, saving the state $85 million for the first six program years and a 3.1:1 ROI. Program Year Savings ROI /2010 $7.7 Million 2.4 : /2011 $12.8 Million 3.1 : /2012 $13.8 Million 3.9 : /2013* $8 Million 2.3 : /2014* $19.9 Million 3.4 : /2015 $24.7 million 3.2:1 *Program Year 4: Enrolled Clients dropped as healthier populations shifted to the CCOs. *Program Year 5: Enrolled Clients grew as new populations were added to the program by OHA and CMS. $30,000,000 $25,000,000 $20,000,000 $15,000,000 $10,000,000 $5,000,000 $0 Program Year Savings ( ) PY1 PY2 PY3 PY4 PY5 PY6 9

10 OHPCC Hepatitis-C Pilot Project We began coordinating care for antiviral treatments available for patients with the Hepatitis-C Virus. There are 21 OHP Open Card members participating in the pilot. Nine members have successfully completed their therapy. More than 952 doses of medication have been monitored through the pilot. We identified and intervened in three cases where a potential enrollment lapse was possible or probable. We identified two members with third party liability (insurance) responsible for covering the costs of treatment (saving the state approximately $200,000). So far, there is a compliance rate of 99.5 percent (947 of 952 doses of medication were taken by participants in the pilot project). Several studies suggest that patients on their own have a compliance rate of approximately 70 percent. 10

Behavioral Health Initiatives We are supporting the state s efforts to reduce state hospital utilization by determining the proper placement of patients in community-based, person-centered services.

11 Behavioral Health Initiatives We are supporting the state s efforts to reduce state hospital utilization by determining the proper placement of patients in community-based, person-centered services. These services are included in Oregon s state plan and are part of Oregon s Home and Community-Based Services providing needed support for individuals to live integrated in the community and have experiences, including employment, just like other members of the community, supporting an individual s independence and dignity. There are two types of behavioral services in the state plan: Home Based Habilitation Services are provided to an individual who needs assistance with activities for daily living. Behavioral Habitation Services are designed to assist an individual in attaining or maintaining their maximum level of independence. 11

12 CCO & Open Card Relationship The OHPCC serves as the backstop for health system transformation, ensuring nobody falls out of coverage. Network adequacy continues to be an issue for the managed care delivery system. OHPCC is a vital option of last resort for OHP members in need of care. The OHPCC supports health system transformation by separating special populations from the capitated budgets of the CCOs, enabling them to further innovate the care delivery model improving health outcomes for the vast majority of OHP members. We are committed to a warm-transfer of member information if and when they are ready to enroll into a CCO to ensure an easy transition for both the CCO and the member. 12

13 How does KEPRO Integrate services? KEPRO leverages Health Intelligence Data, partnerships with providers and the Indian Health Service, as well as specialists in the field to ensure that each member receives tailored, holistic and compassionate care coordinated around their entire healthcare experience. KEPRO s Clinical Assessment Census Information Percolator Data Care Coordination Social Services Primary Care Medication Management Medical History Claims History Case Worker Referrals Discharge Planning Transition of Care Partnerships & Resources Coordinate All Available Resources Jointly Develop Plan of Care Enhanced Care Coordination Coordination with Indian Health Service and Native American Liaison Specialists Service Assessments Member Referrals Authorizes Services & Care Coordinates with KEPRO Nurses Provides in Home Presence Face-to-face Member Interaction 13

14 Our KEPRO Oregon Team John R. DiPalma Executive Director since 2012 Dr. Jeff McWilliams Medical Director since 2012; Board Certified Oncologist/ Hematologist Melissa Golden Data and Reporting Analyst since 2010 Jude McAuliffe-Treinen Quality Improvement Coordinator since 2015 Kevin Minor Behavioral Health Services Supervisor since 2013 Sheri Kellams, RN Clinical Care Coordinator Supervisor since 2009 Cortnee Riddle, LPN Care Coordinator Supervisor since 2012 Direct Service Staff comprised of: Clinical licensed staff : assist patients by phone & face-to-face in the field assessments, medication reconciliations, connecting to a medical home, coordinating with community resources, closing gaps in medical care, etc. Includes Registered Nurses (RN), Licensed Practical Nurses (LPN) and Licensed Clinical Social Workers (LCSW) Care Coordinators : non-clinical: answer phones, assist patients with community referrals, etc. 14

Improving Care for Dual Eligibles through Health IT

Los Angeles, October 31, 2012 Presentation Improving Care for Dual Eligibles through Health IT The National Dual Eligibles Summit Duals Market is sizable Medicare and Medicaid Populations Medicaid Total