Targeting Interventions for the Highest-Need, Highest-Cost Medicare-Medicaid Enrollees: Health Plan Approaches

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1 Targeting Interventions for the Highest-Need, Highest-Cost Medicare-Medicaid Enrollees: Health Plan Approaches July 21, 2015 For Audio Dial: Passcode: Promoting Integrated Care for Dual Eligibles (PRIDE) is supported by The Commonwealth Fund wwwchcsorg

2 Questions? To submit a question, please click the question mark icon located in the toolbar at the top of your screen Answers to questions that cannot be addressed due to time constraints will be shared after the webinar 2 2

3 About the Center for Health Care Strategies A non-profit health policy center dedicated to improving the health of lowincome Americans 3

4 Agenda I Welcome and Introductions II Identifying High-Need, High-Cost Medicare-Medicaid Enrollees through Predictive Modeling for Targeting Services and Interventions III Questions and Discussion IV Targeting Housing and Supportive Services to Promote Community Living and Independence V Questions and Discussion 4

5 Medicare-Medicaid Enrollees are a High-Need Population 107 million Medicare-Medicaid enrollees 1 in 5 Medicare enrollees are dually eligible More likely than Medicare- or Medicaid-only enrollees to have multiple, chronic health conditions More than 40% use LTSS 33% are under AND OVER UNDER 65 More likely to have been diagnosed with 3+ chronic conditions 25% have a behavioral health disorder Enrollment increased 8% since % have a behavioral health disorder Enrollment increased 20% since 2006 Sources: Medicare-Medicaid Coordination Office February 2014 Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2013; and Congressional Budget Office June 2013 Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies 5

6 Promoting Integrated Care for Dual Eligibles (PRIDE) Supported by The Commonwealth Fund Brings together seven health care organizations to identify and test innovative strategies that enhance and integrate care for Medicare-Medicaid enrollees PRIDE participants: - CareSource (OH) - Together4Health (IL) - Commonwealth Care Alliance (MA) - UCare (MN) - Health Plan of San Mateo (CA) - VNSNY CHOICE (NY) - icare (WI) 6

7 Introductions Brianna Ensslin Program Officer Center for Health Care Strategies Amanda Harcus Lead Financial Data Analyst Independent Care Health Plan (icare) Lisa Holden Director of Care Management Independent Care Health Plan (icare) Ed Ortiz Director of Provider Network Development & Services Health Plan of San Mateo Chris Esguerra, MD Deputy Chief Medical Officer Health Plan of San Mateo 7 7

8 Center for Health Care Strategies Amanda Harcus, icare July

9 Why Predictive Analytics? Focus on areas of greatest opportunity to make a difference Actionable information for care coordinators and aligned providers Member level stratification for more effective/efficient care coordination Strengthened ability to manage costs and quality Why Milliman PRM Analytics? Concerns Newer (but Milliman endorsed) tool Narrowed information & reports Middle-cost solution Uncertain ROI value Comprehensiveness Off-sets Current machine-learning algorithms Focused and formatted information Speed to deployment (90 days) Proposed 3% MLR savings estimate Staff buy-in 9

10 icare CC 1 icare CC 2 icare CC 3 icare CC n icare RN/NP 1 icare RN/NP 2 icare RN/NP 3 icare RN/NP n 10

11 Member 1 Member 2 Member 3 Member n DOB 1 DOB 2 DOB 3 DOB n 11

12 Member 1 Member 2 Member 3 Member n DOB 1 DOB 2 DOB 3 DOB n 12

13 Member n Date 1 Date 2 Date 3 Date n Specialty Phy sician Specialty Phy sician Specialty Phy sician 13

14 Member n 14

15 Member n Date 1 Date 2 Date 3 Date n Prov ider 1 Prov ider 2 Prov ider 3 Prov ider n 15

16 16 Member n Date 1 Date 2 Date 3 Date n Date 1 Date 2 Date 3 Date n Prov ider 1 Prov ider 2 Prov ider 3 Prov ider n

17 Member n Date 1 Date 2 Date 3 Date n Date 1 Date 2 Date 3 Date n Date 1 Date 2 Date 3 Date n Prov ider 1 Prov ider 2 Prov ider 3 Prov ider n 17

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21 Evaluation IT Perspective CM Perspectives Data Data Standard Format Good In = Good Out Automated File Production User Interface Drag & Drop to File Transfer Protocol Easy to Navigate & Filter User Interface Easy to Interpret Straightforward Exports to Excel (3000 lines) Easy to Navigate and Filter Each User is Licensed Requested Changes Make county a filter option Acquire a backend copy of the database details/results Incorporate the PRM information into our care management system Add additional chronic conditions to filtering options current limit is 7 Add company logo to exported reports Add user-defined chronic condition groupings 21

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23 Center for Health Care Strategies Lisa Holden, icare July

24 Plan Description Observation Goals Predictive Analytics The Milliman PRM tool is predictive in determining members who would benefit from intensive care coordination PRM could be used to identify members with potentially avoidable costs compared to those members with unavoidable high costs Transfer these identified members into the icare Specialty Services (High Risk) Team intensive pre-crisis intervention 24

25 Profile #1 Member PRM Avoidable Costs Prior Risk Rating PRM Profile History Female, 48, Co-Hab, DIA, CKD, Smoker $10,300 next 6 months Low Findings Acton No glucometer, no dialysis Engage in special team care 25

26 Profile #2 Member PRM Avoidable Costs Prior Risk Rating PRM Profile History Male, 71, Old ER Data, DIA, CHF $11,900 next 6 months Low Findings Action Member highly self-activated Disengage, refer to LVAD care 26

27 Profile #3 Member PRM Avoidable Costs Prior Risk Rating PRM Profile History Female, 63, DIA, BH Issues $79,300 next 6 months High Findings Action Irregular dialysis, high inpatient use Provider/plan surround, education 27

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29 Reasons 24-Month look-back is moving Plan interventions make a difference Machine learning is continuous in testing predicted results Member conditions change Discussion The Milliman algorithm relies on a look-back of the most recent 24 months of claims data, updated each month Effective interventions will reduce the most recent months of costs causing a reduction in risk The algorithm components are being adjusted/re-weighted for accuracy as predicted results are changed to actual Member data available via inpatient rosters, encounters, and emergency department reports change even outside interventions 29

30 Plan Personal Coaching Wellness Clubs Telemetrics Description Observation Goals Community Health Worker/Health Coach Members respond to specialists who live in the same community, share ethnicity, a common language, socioeconomic conditions and life experiences Train members in how to improve their selfmanagement of conditions and use of healthcare resources Community Wellness Program Members benefit, if engaged, from Wellness Programs to increase knowledge, skills and abilities necessary to better self-manage healthrelated behaviors Improve the member s understanding and ability to self-manage their own conditions 24/7 monitoring of key health conditions Members can adopt self-monitoring behaviors with Wi-Fi enabled assists that improve the response time of professional caregiver support Improve monitoring critical health conditions and accelerate response times 30

31 In-Home Health Coaching 31

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34 Activation Signals 34

35 Healthy Living with Diabetes -- Aurora-Sinai Medical Center What s in it for Me? People taking this workshop show: 35

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37 Concurrent ROI Evaluation PRM-Related Action Plans Coach Club Tele-Monitor Investment $ 1) $$ ( $) 2) $$ ( $) 3) $$ ( $) 4) $$ ( $) 5) $$ ( $) 6) $$ ( $) 7) $$ ( $) 8) $$ ( $) a) Total Invested $$ b) PRM Projected Savings $$ c) Actual Savings $$ d) ROI c) a) 37

38 Continuing Concerns and Ambitions Prepare internal protocols for STOP/START of PRM-based interventions Establish intervention boundaries defined by law of diminishing returns Concurrently drop/add/refine ROI-based opportunity initiatives End-of-life Care Pre-diabetic Care Medication Therapy Drive selected PRM filtering by already developed intervention strengths Share member-level risk information within the prior authorization process Attach non-claims data to the PRM Analytics 20 algorithm Improve understanding of the PRM Analytics algorithm Review false negatives to improve predictive accuracy Assess PRM Analytics level through all-in Medicare Medical Loss Ratio trend Integrate predictive information with the TruCare electronic care record 38

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40 Questions? To submit a question, please click the question mark icon located in the toolbar at the top of your screen Answers to questions that cannot be addressed due to time constraints will be shared after the webinar 40 2

41 Effective Targeting of Services and Supports HPSM Community Care Settings Pilot PRIDE Webinar July 21, 2015

42 Overview What is the Pilot? Pilot Structure Pilot Participant Process Targeting Participants Participant Engagement Spotlight: Housing Strategy Member Impact Stories Appendix A: Case-Mix Indexing Tool Appendix B: Participant Dashboard 42

43 What is the Pilot? The Community Care Settings Pilot (CCSP) is our highest intensity care management program Focused on deinstitutionalization and promoting community living for vulnerable members Test-bed for incremental services and tools Concept developed Jan/2013, Launched Aug/2014 Unique features for members include: 1:20 case management (MSW/LCSW) Significant face-to-face contact Housing services & retention Multi-disciplinary core group care planning & oversight 25+ participants include county government agencies For appropriate members, CCSP will deploy whatever services are necessary to migrate out of or avoid LTC residency 43

44 Pilot Structure Operated in partnership with two community-based organizations selected through an RFP: Institute on Aging (IOA): case management and oversight Brilliant Corners: housing services and retention Housing Services (Brilliant Corners) Medical Services & Providers HPSM Intensive Transitional Case Mgmt (IOA) Community & County-Based Resources CCSP leverages a number of resources to support operations: State 1115 waiver programs (ALW, CCT, IHO) County programs (IHSS, CBAS, MSSP) Health benefits and Care Plan Optional (CPO) services Local funding 44

limited resources Appropriateness of services Safe and successful discharges Longevity in the community Pilot as

45 Pilot Participant Process Recalibration & Transition Migration & Stabilization Population Segmenting Engagement & Planning Participant Identification Phases in the participant cycle are designed to ensure: Effective use of limited resources Appropriateness of services Safe and successful discharges Longevity in the community Pilot as a test-bed: lessons learned from deploying this process have already driven change across the larger HPSM program 45

46 Targeting Participants Population segmenting: member groupings best fit to pilot goals & services LTC Residents Needs Assessment ~10-30% of LTC residents able to migrate to lower level of care SNF Diversions LTC Avoidance Acute health incidents prompting change in health or functional status Community Diversions Extending Independence Individuals struggling in the community, at-risk of acute incident or LTC admission Participant identification: sources of individual members appropriate for the program SNF Staff HPSM Case Managers Hospital Discharge Planners High Utilizer Reports County Agency Case Managers Supportive Housing Managers Social Service Programs PCPs 46

Participant Engagement Once participants are identified, prep work begins: Intake Form Completed Scored by Case-Mix

management phases: Once service is connected, participants receive intensive CCSP case management for 9-12 months:

solving Regular contact Skills development Crisis intervention Transition Phase Resolve unmet goals Promote

47 Participant Engagement Once participants are identified, prep work begins: Intake Form Completed Scored by Case-Mix Indexing Tool Assessed Face-to- Face by CM Presented to Core Group Care Plan Created Service Connected Stepped case management phases: Once service is connected, participants receive intensive CCSP case management for 9-12 months: Implementation Phase Successful discharge Frequent home visits PCP engagement Home setup Stabilization Phase Problem solving Regular contact Skills development Crisis intervention Transition Phase Resolve unmet goals Promote independence Ensure safety Transfer of case Members are transitioned to a different CM tier Brilliant Corners housing retention services continue 47

48 Spotlight: Housing Strategy Housing services are one of the unique elements of CCSP, delivering a range of supports for project participants: Person-centered planning Owner-resident liaison Housing portfolio management Rental subsidy administration Targeted residential settings: Affordable housing waitlist management Unit repairs and modifications On-call/ 24-hour response Unit Habitability and wellness checks Existing Home Affordable Supportive Housing Scattered-Site Housing RCFE/ ARF Assisted Living Housing has been the main barrier to LTC discharge for many members, our goal is to remove that barrier 48

49 Member Impacts Intensity of assessment and case management has identified and resolved many immediate member issues prior to transition Medications, provider engagement, DME needs, IHSS hours Examples of key impacts for transitioned members: Situation Upon Enrollment Stroke LTC SNF (1 year) Pending eviction from long-time home (affordable senior apartment) Shoulder replacement & rehab LTC SNF (1 year) Lost Section 8 apartment while in LTC Complications from hysterectomy LTC SNF (1 year) Depression, substance use Previously lived in car, MHRC, Section 8 apt Post-Transition Impacts Returned home (eviction prevented by case manager) Connected to CBAS (5x per week) and 4 other supportive services Engaged socially in the community Section 8 Apartment (voucher extended by case manager & landlord convinced to accept it) Overjoyed to have a home again Placed in stable apartment Regularly visiting community behavioral health provider and PCP Stroke, diabetes with vision loss LTC SNF (2 years) Previously experienced homelessness Transitioned to community RCFE Bonded with house dog at RCFE Volunteering with the SPCA Self-managing diabetes for the first time 49

50 Appendix A: Case-Mix Indexing Tool Best Case Scenario points SNF Resident Line of Business Target Population Prioritization Factors Cal MediConnect +3 Primary barrier to discharge is housing +1 or Care Advantage Expressed preference and motivation to return to community +1 SNF Resident +3 Behaviors unlikely to jeopardize potential placement +1 Client income source expected to support community living +1 Medi-Cal only +1 Formal or informal supports motivated to assist client +1 Current placement >90 days +1 Cal MediConnect or Care Advantage 12 pts Medi-Cal only 10 pts Line of Business Target Population Prioritization Factors Cal MediConnect +3 Primary barrier to discharge is housing +1 or Care Advantage Expressed preference and motivation to return to community +1 SNF Diversion +2 Behaviors unlikely to jeopardize potential placement +1 Client income source expected to support community living +1 Medi-Cal only +1 Formal or informal supports motivated to assist client +1 DxCG score > 75th percentile of HPSM members +1 SNF Diversion Cal MediConnect or Care Advantage 11 pts Medi-Cal only 9 pts Alternative Case Scenario 8 points Line of Business Target Population Prioritization Factors Cal MediConnect +3 Current housing at risk and/or accessibility issues identified +1 or Care Advantage Recent history of missing multiple primary or specialty care appts +1 Community Diversion +1 Recent history of lack of engagement with service providers +1 Case management needs exceed those available in community +1 Medi-Cal only +1 Formal or informal supports in need of support to assist client +1 DxCG score > 75th percentile of HPSM members +1 Community Cal MediConnect or Care Advantage 10 pts Medi-Cal only 8 pts 50

51 Appendix B: Participant Dashboard Enrolled: Pretransition Transitioned Transitioned Enrolled: Closed: Prospects W aitlisted C losed Deferred Totals Target Population # % # % # % # % # % # % # % LTC Resident 10 91% 16 36% 37 90% 15 44% 1 17% 5 45% 21 51% SNF Diversion 0 0% 6 14% 2 5% 9 26% 1 17% 3 27% 2 5% Community Diversion 1 9% 22 50% 2 5% 10 29% 4 67% 3 27% 18 44% 100% 100 % 100% 100% 100% ### 100% HPSM Line of Business # % # % # % # % # % # % # % Care Advantage/CMC 8 73% 18 41% 16 39% 23 68% 5 83% 6 55% 18 44% Medi-Cal Only (No Medicare) 3 27% 13 30% 12 29% 4 12% 1 17% 4 36% 10 24% Medi-Cal Only (Medicare opt out) 0 0% 13 30% 13 32% 7 21% 0 0% 1 9% 13 32% 100% 100 % 100% 100% 100% ### 100% Referral Source # % # % # % # % # % # % # % SNF 0 0% 20 45% 36 88% 20 59% 1 17% 5 45% 12 29% Community 0 0% 23 52% 2 5% 10 29% 4 67% 2 18% 17 41% HPSM % 1 2% 3 7% 4 12% 1 17% 4 36% 12 29% 100% 100 % 100% 100% 100% ### 100% Anticipated Housing Need # % # % # % # % # % # % # % Scattered Site 9 20% 12 29% 5 15% 0 0% 3 27% 11 27% RCFE N/A 21 48% 19 46% 16 47% 1 17% 5 45% 20 49% Other 8 18% 6 15% 3 9% 0 0% 2 18% 1 2% None 6 14% 4 10% 10 29% 5 83% 1 9% 9 22% 100 % 100% 100% 100% ### 100% Reasons for Deferral/Closure # % # % # % # % # % # % # % Member declined services 0 0% 5 45% 13 32% Death/hospice 2 33% 1 9% 8 20% Needs met by other CM provider N/A N/A N/A N/A 0 0% 0 0% 3 7% No longer needs services 4 67% 3 27% 7 17% Not appropriate for program 0 0% 2 18% 10 24% 51

52 Questions? To submit a question, please click the question mark icon located in the toolbar at the top of your screen Answers to questions that cannot be addressed due to time constraints will be shared after the webinar 52 52

53 Contact Information Brianna Ensslin Amanda Harcus Lisa Holden Ed Ortiz Chris Esguerra 53

54 Visit CHCSorg to Download practical resources to improve the quality and cost-effectiveness of Medicaid services Subscribe to CHCS updates to learn about new programs and resources Learn about cutting-edge efforts to improve care for Medicaid s highest-need, highest-cost beneficiaries wwwchcsorg 54

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