Managed Long Term Services and Supports, an. Brian Stever, BSN RN Director of Health Informatics Presbyterian Senior Living April 28, 2016

Transcription

1 Managed Long Term Services and Supports, an update Brian Stever, BSN RN Director of Health Informatics Presbyterian Senior Living April 28, 2016

2 Agenda What is Managed Long-Term Services and Support, MLTSS? Why this focus on LTSS? What does this mean for Case Mix in PA? What s next in the process/recommendations? 2

3 What is Managed Long-Term Services and Supports? Managed Long Term Services and Supports is the delivery of long-term services and supports (LTSS) through capitated Medicaid managed care programs. It refers to an arrangement between Pennsylvania's Medicaid programs and contractors. The contractors receive capitated payments (flat, fixed fees per participant based on their aggregate costs) for LTSS and are accountable for the health and welfare of participants through the delivery of services and supports that meet quality and other standards set in the contracts. The LTSS contracts were defined in an Request for Proposal, RFP, that was released on March 1 st 3

4 What is

5 Community Health Choices Problem Statement Governor Wolf is committed to increasing opportunities for older Pennsylvanians and individuals with physical disabilities to remain in their homes. To do so, the governor has directed the Departments of Human Services and Aging (PDA) to develop and implement a Managed Long-Term Services and Supports (MLTSS) program for older Pennsylvanians and adults with physical disabilities called Community HealthChoices (Community Health Choices). 5

6 Community Health Choices Goals Enhance opportunities for community-based living for Participants through improved person-centered service planning and performance incentives. Strengthen coordination of LTSS and other types of healthcare, including Medicare and MA services for Dual Eligible individuals. Enhance quality and accountability. Increase efficiency and effectiveness of healthcare and LTSS. Promote the expansion of team-based approaches to service delivery (i.e. patient centered medical homes). Promote community-based public health initiatives. Increase consumer access to needed services, especially in rural and underserved areas of the Commonwealth. 6

7 Community Health Choices Population The Community Health Choices Program is the Commonwealth s statewide mandatory Medicaid managed care program through which Participants will receive Medical Assistance (MA) physical health services and Long Term Services and Supports (LTSS). Community Health Choices will serve the following Participants: Adults age 21 or older who require MA LTSS (whether in the community or in private or county nursing facilities) because they need the level of care provided by a nursing facility or an intermediate care facility for individuals with other related conditions (ICF/ORC). Dual Eligibles age 21 or older whether or not they need or receive LTSS. 7

8 Community Health Choices Components Covered services include: Long-term Services and Supports in the form of Nursing Facility Services or Home and Community- Based Services. Physical Health Services such as, but not limited to: Hospital-based services Pharmacy Primary Care Physician and Specialist Services Durable Medical Equipment Transportation Emergency Services Hospice 8

9 Community Health Choices Components Community Health Choices Coordination Objectives: Includes: Coordination of services available through Medicare, Medicaid LTSS, Medicaid Physical Health Services, and Medicaid Behavioral Health Participant assistance in accessing, locating and coordinating needed Covered Services and non- Covered Services such as social, housing, educational and other services and supports. Monitoring provision of services to ensure that assessed needs are being met. 9

10 Impact studies of early MLTSS Focus on Community- Based LTSS Increased emphasis on providing LTSS in a person s home. Hospital Use Declined Physician Services Increased Outcomes Improved (Less often studied) Hospital use was reduced in all but one program where studied Primary care visits increased in all programs where studied Slower rate of functional loss Lower mortality

11 Community Health Choices Request for Proposal Summary Nursing Facility Services The CHC-MCO is responsible for payment for Medically Necessary NF services, including bed hold days and up to fifteen (15) days per hospitalization and up to thirty (30) Therapeutic Leave Days per year if a Participant is admitted to a NF or resides in a NF at the time of Enrollment. The CHC-MCO must, in coordination with the Department, monitor for completion of all NF related processes, including but not limited to: PASRR process, specialized service delivery, Participant s rights, patient pay liability, personal care accounts or other identified processes. 11

12 Community Health Choices Request for Proposal Summary Nursing Home Transition (NHT) is located in the Draft Agreement, Section V: Program Requirements, L. Nursing Home Transition NHT will also be absorbed as an administrative function of CHC-MCOs. CHC-MCOs will have the option to contract with existing NHT providers. This community is generally a less expensive venue for services. CHC-MCOs have an inherent interest to transition participants into the community. CHC-MCOs must provide Nursing Home Transition activities for those residents in LTC that would like to transition back to their homes or other community-based settings. 12

13 Community Health Choices Regional Map 13

14 Community Health Choices Roll-Out Schedule Transitioning existing fee-for-service long-term services and supports (LTSS) to a capitated managed care (MC) model Phased roll-out beginning January 1, 2017 in southwestern Pennsylvania. 19

15 CHC Southwest Region (01/01/2017) 15

16 CHC Southeast Region (01/01/2018) 16

17 CHC Lehigh-Capital Region (01/01/2019) 17

18 CHC Northwest Region (01/01/2019) 18

19 CHC Northeast Region (01/01/2019) 19

20 What does this mean for Case Mix in PA? Case Mix in the state of Pennsylvania will cease to be. The first six (6) months of the process going live in any region will allow for the continuation of the current process while the MCOs set up their new processes. 20

21 What we do know about Case Mix in PA The first six (6) months, no change in process After this timeframe, MCOs have the right to change Network Participation may narrow based on conversations with the MCOs that have been engaged in the process Participant Choice and Changes with MCOs 21

22 What s next in the process/recommendations? The MCOs have begun to ask for specific information about the services that communities can provide to residents that we serve. For example, Dental care Podiatry Optometry services Transportation Restorative services Etc. 22

23 Our Aging Services Network Use a state of the art Electronic Health Record Inpatient and Outpatient Rehabilitation Services A comprehensive approach to discharge planning Hospice and End-of-Life Care Adult Day Services Personal Care with memory supportive services Chaplain Services Chapel/Meditation Room Wellness Clinic A fully function Wellness Center with fitness equipment and a pool Transportation Services Dental, Optical, and Podiatry Services

24 More recommendations If your community is part of a chain or has a variety of levels of care, make sure that the MCOs know and understand that fact Emphasize what makes you a good partner for the MCOs Quality of care ALOS Etc. Do your own research on the MCO What their needs are How have they provided services in the past Be willing to work with the MCOs in your region Most importantly, stay informed! 24

25 Resource Information Community HealthChoices Website: althcho ices/index.htm#.vkyj23arrhf MLTSS SubMAAC webpage link: ormati onforadvocatesandstakeholders/mltss/index. htm#.v kykanarrhe Comments to: 25

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