Building on Your Home Visits: Medication, Psychosocial & Fall Risk Assessments and Follow Up. Lessons learned from CBOs contracting with Healthcare

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2 Building on Your Home Visits: Medication, Psychosocial & Fall Risk Assessments and Follow Up Lessons learned from CBOs contracting with Healthcare

3 Thanks to our funders for helping us be trailblazers With gratitude to the John A. Hartford Foundation & Archstone Foundation

4 Partners in Care Foundation Changing the Shape of Healthcare Partners is a think-tank and a proving ground Partners changes the shape of health care by creating high-impact, innovative ways of bringing more effective clinical and social services to people and communities Partners direct services test, measure, refine and replicate innovative programs and services, and bring needed care to diverse populations

5 Our Contracts Care Transitions Coaching & Bridge HomeMedsPlus In home assessment & med review, plus 30, 60 or 90 days of care coordination Evidence based self management programs LTSS Waiver continuation under duals demonstration Adult Day Health eligibility determination RN face to face assessment Safe discharge for mental health/dual diagnosis/homeless after medical admission Locate duals and connect with med group PCP Health Risk Assessments 911 diversion for frequent callers

6 The place for social services in health care CBOs are essential to providing person centered care

7 What Managed Medicaid/Medicare/ Dual Plans Mean for CBOs Managed care plans are increasingly assuming full (financial) risk for frail adults & people with disabilities including institutionalization and HCBS Many of the traditional services CBOs have long provided are now funded through Managed Care Organizations, meaning new opportunities to identify and serve many more in need

8 Why change business models and contract with health care entities? Seize time of dramatic change integrate healthcare and social services expand by moving health dollars to home and community services under health reform Foundation funding has time limits Use for innovation, not operations Waiver to be absorbed by Medicaid managed Care organizations (MCOs) 40% of our budget before healthcare contracting 20% of our budget after healthcare contracting Older Americans Act stagnant vis à vis growth in 65+ population Healthcare dollars here to stay if positive ROI

9 Health Care s Blind Side RWJF Survey of 1,000 primary care physicians (PCPs): 80% not confident in their capacity to address their patients social needs. 86% said unmet social needs are leading directly to worse health. 76% wish the healthcare system would cover cost of connecting patients to services to meet health related social needs. 1 of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance. Health Care s BLIND SIDE The Overlooked Connection between Social Needs and Good Health, Robert Wood Johnson Foundation, December 2011,

10 Health Care + Social Services = Better Health, Lower Costs! Address social determinants of health Personal choices in everyday life Isolation, family structure/issues, caregiver needs Environment home safety, neighborhood Economics affordability, access Social Service Agencies Have Advantages Time to probe, trust, different authority Cultural/linguistic competence Lower cost staff & infrastructure High impact evidence based programs

11 The Key to succeeding Winning Contracts Strong value proposition quality, clinical results, ROI Ability to translate between social services & healthcare Staff backgrounds include executive level experience in: Hospital Home Health Health Plan Hospice, SNF Board contacts: RN healthcare management consultant Executives from hospitals, health systems, health plans, medical groups PharmD venture capitalist Healthcare lawyer Going to/speaking at healthcare sector meetings and conferences Just Show Up! Movement of staff among plans introduces us

12 Door Openers: Meds, Falls, Quality Results of our interventions appeal to healthcare: HomeMeds SM addresses multiple quality/star domains High risk medications Hypertension control Pain control/assessment Care Transitions with medication reconciliation required by National Committee for Quality Assurance (NCQA) for health plans Fall risk management: % of Medicare members 65+ who fell or had problems with balance or walking in past 12 mo. who received fall risk intervention Providing person centered care improves client satisfaction and (we hope) member retention. "No risk factor for falls is as potentially preventable or reversible as medication use. (Leipzig, 1999)

13 3 Service lines to be offered Evidence based Self Management Independent w/ chronic condition Short term In Home Services At risk for deterioration & high utilization Long term Services & Supports Frail/disabled Stanford Chronic Disease Self Management (Online, Diabetes, Pain, Spanish) Matter of Balance, etc. HomeMeds Care transition coaching In home psychosocial evaluation Service coordination Service coordination Purchase of services (meals, respite, transport, chores)

14 Value Proposition: CBOs & Triple Aim Stanford Self Management Workshops Pain HEALTH Falls HomeMeds A Matter of Balance Healthy Moves COST Care Transitions Coaching ED IP HomeMedsPlus Complex Community Care Management QUALITY Needs Met Member Retention Meals Home visit Transportation

15 CBO Network Service Lines Value Proposition: Who Pays and Who Saves? EOL 25% of all Medicare is Last Year of Life: Duals Plans; Medicare Advantage SNP; ACO/MSSP LTSS & Caregiver Support Care Transitions HomeMeds/Home Safety Assessment Nursing Home Diversion for Duals Plans ED/Hosp: Capitated Providers/Plans Readmission penalties: Hospitals Evidence Based Self Management: CDSMP/DSMP; MOB; Healthy IDEAS; EnhanceFitness; PEARLS; Fit & Strong Senior Center meals, classes, exercise, socialization Chronic Disease Management: Duals Plans; MA SNP Prevention: MA Plans; Capitated Med Groups

16 Results for Our Programs LTSS waiver program for duals Keeps nursing home eligible seniors at home for an average of 5 years! Cost? $357/month vs. $3,000+ for SNF Care Transitions Coaching & Social Services Across 25,000 patients and 11 hospitals, average reduction of 34% and ROI of 1.8:1 HomeMedsPlus Home visit, med rec, pharmacist, psychosocial/ functional assessment, home safety evaluation In physician group post hospital 13% lower rate of ER use & 22% lower rate of readmission w/in 30 days Discovered medication related problems in 63% per pharmacist AFTER hospital medication reconciliation

17 HomeMeds Anchor for successful contracting HomeMeds is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety Translated into healthcare lingo we re doing a home medication review (or reconciliation) and pharmacist intervention Focuses on adverse effects (falls, confusion, dizziness, vitals) then determines if medications may be part of the cause. Targets problems for significance, accessibility to in home staff, and likelihood of positive prescriber response. Cost effective use of geriatric pharmacist for complex problems

18 HomeMedsPlus

19 Facing the future together Networks of CBOs will enable all boats to rise together and give us scale to compete successfully and regionally in post ACA (Affordable Care Act) markets

20 So you won the contract Congratulations! Now, to compete with larger companies and grow potential for contract renewal, you will want to offer: Broad geography Multi specialty services

21 Winning Contracts Isn t Enough Healthcare Changes IT supports targeting/referral Programming to support data exchange Champions at all levels Workflow changes Patient/member motivation Share outcomes data Respect CBO expertise Referrals Acceptance Completion CBO Changes: Better IT systems Better IT security More insurance Accreditation Provider # Motivate health plan CMs to refer & work with us Workflow Understand health plan regulations Motivate patients & participants Address barriers for patients Volume is a prerequisite for sustainability

22 Threats to our Role Build vs. Buy Medicine tends to want to own everything do it themselves National for profits see a large market and have distinctive assets capital, IT and sales Lack of clear methods to identify and refer those needing these services positive ROI for payer We need to bring our distinctive assets and compete against some of theirs We need clear quality metrics to show our effectiveness A challenge to illustrating our impact is many of our private contracts have extremely low referral rates

23 Why Focus on Integrated Networks for Medical Care and Social Services? Improve health for adults with chronic conditions through comprehensive, coordinated, and continuous expert and evidence based services Add supportive social services to medical care Improve health outcomes & reduce cost of medical care ACA and Duals plans opportunity for expanded LTSS Government/Older Americans Act funding threatened. Opportunity to compensate for this through health plans, which are large, often multi regional and multi state

24 Lead Agency Role Engage health payers and negotiate contracts that provide referral opportunities for the whole Network Cultivate potential partnerships with new Network members with skilled staff and new service areas Create criteria and standards for qualifying potential Network members (insurance, staff credentials) Formalize partnerships through subcontracting Engage current Network members in operations trainings and strategic partnership opportunities Create Network wide workflows and procedures for contract start up and implementation Select and adapt Network wide IT systems Fiscal management Quality metrics and oversight systems Case consultation and case review Strategic planning opportunities Obtaining and renewing accreditation

25 Network Development Network development is ongoing: improvements to existing systems/ operations, like IT and hospital workflows; or new contracts call for new geography or new skillsets

26 Why belong to a network? Contracting is expensive Legal fees one contract $40,000+ Contracting is time consuming multiple meetings every week over 9 months ~2,000 hours of senior/ executive team time for one contract Build the relationship materials, business case Negotiate the contract pricing, terms, requirements Roll out the program Develop workflows Policies & procedures Hire & train staff Reporting & evaluation

27 More Reasons to Belong Competition Large national companies promise efficient service, unified IT, analytics, quality assurance Medical Loss Ratio Billing Health Plans must spend 85% on clinical care & quality No more pilots under administrative budget To be clinical, you need license &/or accreditation Accreditation is costly ($33,000+) Requires huge effort better through a single entity. May be required for contracting with health plans other than Medicaid, especially Medicare License: Shared cost for licensed supervision Medicare Provider # Difficult Diverse populations have diverse needs Require a broad range of skills and specialties including: Behavioral health and some of the disability specialties Substance abuse/addiction issues

28 Huge investment in change for healthcare Every meeting with us was a meeting for them Lawyers for them, too These are disruptive innovations/changes for healthcare Dept. Managed Care has to approve every contract Delegation issues with NCQA accreditation Many healthcare entities are regional or statewide Doing this with multiple agencies would be prohibitive Investment will reap an integrated statewide network and coordinated delivery system

29 Why focus on data? Targeting to keep value of services high Demonstrate outcomes to keep/grow contract Show clinical, quality or satisfaction improvements and cost neutrality Show savings &/or reductions in utilization Quality improvement Internal productivity management For advertising For accreditation For your board Add to national knowledge about CBO outcomes

30 Metrics Learning Quality Improvement Keeping Contracts!! % of referrals who previously received intervention Failure study this! % Ineligible for Intervention Use data to refine targeting methods less work for all % Refused Learn who, how, when, why to touch more lives % Unable to reach Analyze by time of day, reason No outputs = no outcomes!

31 Why Join a Network? Large Healthcare Entities want one stop shop Contracting is expensive Legal fees one contract $40,000+ Contracting is time consuming multiple meetings every week over 9 months ~2,000 hours of senior/ executive team time for one contract Build the relationship materials, business case Negotiate the contract pricing, terms, requirements Roll out the program Develop workflows Policies & procedures Hire & train staff Reporting & evaluation

32 More Reasons to Belong Competition Large national companies like APS promise efficient service, unified IT, analytics, quality assurance Medical Loss Ratio Billing Health Plans must spend 85% on clinical care & quality No more pilots under administrative budget To be clinical, you need license &/or accreditation Accreditation is costly ($33,000+) Requires huge effort better through a single entity. May be required for contracting with health plans other than Medicaid, especially Medicare License: Shared cost for licensed supervision Medicare Provider # Difficult Diverse populations have diverse needs Require a broad range of skills and specialties including: Behavioral health and some of the disability specialties Substance abuse/addiction issues

33 Lessons Learned Best practices and caveats for CBOs contracting with health plans and physician groups

34 Caveat Vendor Contracting takes time Time from initial meeting to signing contract can be >1 year. Pricing is vital and complex Communication matters Bi lingual/bi cultural medical/social Handoff from Plan s contracting team to implementation team lost continuity need to keep educating on value of HCBS; Discuss IT needs and solutions before implementing the contract; Partnerships matter Integration with Plan CMs view CBO as partners referrals. Volume = sustainability Getting contract doesn t guarantee volume; ONGOING WORK! Need a way to cover up front investment setting up systems, legal expense, training staff Start up capital

35 Best Practices You cannot over prepare! Playbook define roles/responsibilities for implementation Emphasize the value of communication Insist on ongoing training with Plan s case managers IT that enables CMs to log in and check status of members Fail fast! Mistakes will be made; the sooner you learn from them and move forward, the better off you ll be Underscore your value! Value proposition no margin/no mission for both $$ Quality Accreditation of community based care coordination provides common language between cultures IT that automatically measures effectiveness, performance. Metrics, data for you, the network, & contract partners

36 Contract requirements surprise! No data on laptops or mobile devices Must have data disaster recovery plan (backup & restore) Tested annually and test results submitted to plan Physical Security & Environmental Controls Limit access to those who need it; secure environment Must provide documented data security plan including diagrams, info architecture, risk assessment, policies Annual security audit & report provided to Plan Insurance Privacy Liability and Network Security Higher limits $3 million/$5 million

37 More requirements Same day documentation of every attempt to contact member (Imagine this without IT!) Date, time, notes, plan Document supervision/monitoring by LCSW Provide access for Plan to internal record keeping systems related to Plan members Provide monthly summary of services delivered (and not delivered with explanation) Maintain data system compatible with Plan s and capable of data exchange Secure File Transfer Protocol (SFTP) & Secure required

38 IT Absolutely Required Moving from hundreds of waiver clients to thousands Screening criteria less reliance on humans for referrals Ideal: connect directly to EHRs Enable population health management Plan providing 1000 s of names we sort, process, call, engage Manage workflow for short term work and higher volume Secure communication: internal & with new payers Analytics for external reporting and internal QI Demonstrate outcomes Billing/reconciling payments with multiple contracts/rates/scopes

39 No IT? Do Whatever it Takes!! 70 Column Log Export PDFs to Excel Copy Data TO HomeMeds Pharmacist Log Data

40 Usual work, new standards Our traditional services can improve outcomes for health plans, hospitals, ACOs and provider groups and improve lives for people & families! We just have to do it better & faster New Culture: How high?!! Accountability. Quality. And we have to do it together so we can compete successfully with large national firms

41 New Paths for CBOs Outcomes oriented focus on impact & value Data driven Requires sophisticated IT systems for analytics & interoperability Determine appropriate Risk taking, learning organization Learn from inevitable mistakes Fast feedback loop review data weekly & take action to correct

42 Questions?

43 Contact Partners in Care Foundation June Simmons, CEO Sandy Atkins, VP, Strategic Initiatives Amanda Ghattas, Program Manager, Network Contracting & Systems AG1

44 Slide 43 AG1 we should put the social media links here Amanda Ghattas, 3/11/2016