Health Home Overview 10/1/2013

Transcription

1 Health Home Overview

2 Headline Goes Here Presentation Outline What is a Health Home? Health Home Functions Health Home Core Measure Set Eligibility Roles & Responsibilities Frequently Asked Questions 2

3 Headline Goes Here What is a Health Home? Definition A Health Home is NOT a place A Health Home is the central point for directing patientcentered care and is accountable for reducing avoidable health care costs, specifically: Preventable hospital admissions/readmissions and avoidable emergency room visits; Providing timely post discharge follow-up; And improving patient outcomes by mobilizing and coordinating primary medical, specialist, behavioral health, long-term care services and supports, and community services. Community Services Specialty Care Primary Care Health Home Long Term Care Mental Health Source: Washington State Health Home Essential Requirements Draft Document 3

4 Headline Goes Here What is a Health Home? (cont d) HCA is responsible for qualifying Health Homes through an application process. Molina is contractually obligated to offer Health Homes services delivered by a Qualified Health Home to eligible members. Health Home Structure Lead Entity Care Coordination Organization (CCO) Health Home Authorizing Entity/Network Providers The entity that organizes the network either formally via contracting, or informally via operational agreements/mous An organization contracted with the Lead Entity to provide Health Home Care Coordination Services An entity that provides services to Health Homes members including direct care, social services, coordinating functions, and/or authorizing functions. Source: Washington State Health Home Essential Requirements Draft Document 4

5 Health Home Hierarchy HCA Lead Entity 1 Lead Entity 2 CCO A CCO B CCO C CCO D Care Coordinator 1 Care Coordinator 2 Care Coordinator 3 Care Coordinator 4 Care Coordinator 5 Care Coordinator 6 Care Coordinator 7 Care Coordinator 8 Member A Member C Member E Member G Member I Member K Member M Member O Member B Member D Member F Member H Member J Member L Member N Member P 5

6 Headline Goes Here Health Home Functions Coordinate and provide access to: High-quality health care services informed by evidence-based clinical practice guidelines Preventive and health promotion services, including prevention of mental illness and substance use disorders Mental health and substance abuse services Comprehensive care management and care coordination including support in transitioning from different levels of care (i.e. inpatient to SNF/home; SNF to home) Chronic disease management, including self-management support to individuals and their families. Individual and family supports, including referral to community, social support, and recovery services Long-term care supports and services 6

7 Health Home Core Measure Set Measure title Alignment with other CMS programs Adult BMI Assessment Medicaid Adult Core Set, HEDIS Ambulatory Care-Sensitive Condition Admission Care Transition Transition Record Transmitted to Healthcare Professional Follow-up After Hospitalization for Mental Illness Medicaid Adult Core Set Children s Core Set, Medicaid Core Set, HEDIS Plan All Cause Readmission Screening for Clinical Depression and Follow-up Plan Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Controlling High Blood Pressure Adult Core Set, HEDIS PQRS, CMS QIP, Medicare Shared Savings Program, Medicaid Adult Core set, Meaningful Use 2 Meaningful Use 1 & 2, Medicaid Adult Core Set, HEDIS Million Hearts, Medicaid Adult Core Set, Meaningful Use 2, ACO Measure Core Measurement Set Details 7

8 Headline Goes Here Eligibility Medicaid high cost/risk persons with chronic illness (PRISM score 1.5+ with one or more chronic conditions) are eligible for Health Homes services The HCA will identify eligible Health Home members and report to the MCOs in their monthly 834 (Eligibility) files. Members will be passively enrolled into the program. It is the Care Coordinator s job to reach out these members and encourage them to participate. The program is completely voluntary and the member has the right to opt-out or withdrawal at any time. 8

9 Role of a Lead Entity A Lead Entity is composed of community based providers and qualified by the state to provide Health Home Services to eligible beneficiaries. Health Home Care Coordination Services Include: Comprehensive care management Comprehensive transitional care and follow-up Referral to community and social support services Care coordination and health promotion Patient and family support Use of information technology to link services, if applicable 9

10 Role of a Lead Entity (cont d) Smart assign eligible Health Home members to a Care Coordination Organization Demonstrate a capacity to use health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers, and provide feedback to practices, as feasible and appropriate. Establish a continuous quality improvement program, and collect and report outcomes data. 10

11 Role of a CCO Care Coordination Organization (CCO) is responsible for delivering the six Health Home care coordination services to the eligible members. Health Home Care Coordination Services Include: Comprehensive care management Comprehensive transitional care and follow-up Referral to community and social support services Care coordination and health promotion Patient and family support Use of information technology to link services, if applicable 11

12 Role of a CCO (cont d) Contract with a Lead Entity to provide Care Coordination services Smart assign a Care Coordinator to assigned Health Home eligible members Hire and organize community based Care Coordinators Ensure Care Coordinators are trained and submitting pertinent information to the Lead Entity as required by the MOU. Submit claims to the Lead Entity for Care Coordination services according to defined rate tiers 12

13 Headline Goes Here Role of a Care Coordinator Care Coordinators will develop a person-centered care plan (Health Action Plan or HAP) for each individual enrolled in a Health Home that coordinates and integrates all of his or her clinical and non-clinical health-care related needs and services. Deliver the six pre-defined Health Home Care Coordination benefits to Health Home eligible members. Benefits must be provided through high touch, in-person registered nurses, licensed practical nurses, Physician's Assistants, BSW or MSW prepared social workers, and Chemical Dependency Professionals. Outreach to eligible members and complete a Health Action Plan (HAP) for all consenting members. Follow up on and maintain HAP goals, outcomes, and barriers. Facilitate care among service and network providers and members to ensure collaboration Source: Washington State Health Home Essential Requirements Draft Document 13

14 Headline Goes Here Authorizing Entities / Network Partners Health Home Networks must include local community agencies that authorize Medicaid, state or federally funded mental health, long-term services and supports, chemical dependency and medical services. Examples Primary Care Providers/FQHCs/Medical Homes Community Mental Health Agencies- CMHAs Regional Support Networks-RSNs Accountable Care Organizations-ACOs Public Health Districts Managed Care Organizations MCOs Area Agencies on Aging Charities Substance Use Disorder providers Network Alliances Hospitals Housing Community Support Agencies 14

15 Desired Outcomes Collaboration and Coordination Self management of chronic conditions Increased member health outcomes 15

16 FREQUENTLY ASKED QUESTIONS 16

17 FAQs Q: Where is Molina a Lead Entity? A: MHW is a Lead Entity in the following counties: Coverage Area 1: Clallam, Jefferson, Grays Harbor, Mason, Kitsap, Pacific, Thurston, and Lewis Coverage Area 2: Whatcom, Skagit, San Juan Coverage Area 6: Chelan, Okanogan, Douglas, Grant, Lincoln, Ferry, Stevens, Adams, Pend Oreille, Spokane, Whitman Coverage Area Map 17

18 Coverage Area Map 18

19 FAQs Q: What is Molina s Health Home role in the rest of the state? A: Molina is required by their Healthy Options contract to provide Health Home services to all eligible members throughout Washington state, either by being a Lead Entity or contracting with a Lead Entity. In areas where MHW is not a Lead Entity, they have fulfilled their obligation by contracting with a Lead Entity, who will provide care coordination services to MHW members on behalf of MHW. 19

20 FAQs Q: Who are Molina s Care Coordination Organizations? A: MHW has contracted with several CCOs across the 3 coverage areas: Molina Employed Care Coordinators Behavioral Health Northwest (BHN) Working with several others in coverage areas to complete contract. List will be on webpage when finalized 20

21 FAQs Q: What are the benefits of Health Home services to the providers? A: Health Homes provides more care coordination assistance to PCPs and specialists. It also enables communication among providers to know what services are being given to the member other than their specialty. 21

22 FAQs Q: How do providers know if a member is eligible for Health Home services? A: The provider can look up the member on ProviderOne, or search for the member through Molina s Web Portal. Also, care coordinators will be in contact with PCPs, authorizing entities and Specialists directly regarding enrolled Health Home beneficiaries. It is the care coordinator s responsibility to make sure information is being disseminated among providers to ensure proper coordination of care. 22

23 FAQs Q: How could a provider get a member qualified for Health Home services if not already identified? A: Call Molina Member Services (800) Tell them you want to refer a member for Health Home services and give the representative the referred member s name and member ID. A Health Home supervisor will assess the member s eligibility using a Clinical Assessment tool provided by the HCA. If the member qualifies, the supervisor will notify the HCA of the referral. If the HCA approves, the member will be identified on the next 834 (Eligibility) file sent to Molina. 23

24 FAQ Q: How do providers contact Molina regarding Health Homes? A: For provider questions or to refer a member, call (800) Or the Molina Health Home team directly at WAHealthHome@molinahealthcare.com 24

25 Useful Links HCA Health Home website Health Action Plan (HAP) Coverage Area Map Molina Healthcare of Washington website MHW Web Portal for Providers MHW Member Services (800) MHW Health Home team Any questions pertaining to the presentations, please 25