HEALTH HOMES SUBCOMMITTE OF THE INTEGRATED DELIVERY SYSTEM REFORM (IDS) WORKGROUP MEETING MINUTES Meeting Date: 11/26/2014 Meeting Location: JRTC

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1 HEALTH HOMES SUBCOMMITTE OF THE INTEGRATED DELIVERY SYSTEM REFORM (IDS) WORKGROUP MEETING MINUTES Meeting Date: 11/26/2014 Meeting Location: JRTC 16th Floor Back Video Conference Room, Chicago; Capitol 205, Springfield Approval: Final

2 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/ ATTENDANCE See Separate Meeting Attendance List 2. MEETING LOGISTICS Building: JRTC 16th Floor Back Video Conference Room, Chicago; Capitol 205, Springfield Remote Access Tools Used: Phone number: (888) Access Code: MEETING START Meeting Schedule Start: 10:00am Meeting Actual Start: 10:02am Meeting Scribe: Sharon Post, Health & Medicine Policy Research Group 4. AGENDA A. WELCOME AND INTRODUCTION, Michael Gelder Health homes represent an opportunity for enhanced federal matching funds that also aligns with the ongoing transformation of the Illinois Medicaid system. GOHIT is completing its work, and the recommendations from the workgroups build a strong base that will be presented to the new administration s transition team and to stakeholders/advocates. The report can serve as a platform to keep moving Illinois in the direction toward more effective health care delivery. B. DISCUSSION OF DRAFT HEALTH HOME CONCEPT PAPER HFS Director Julie Hamos introduced the concept paper, explaining that HFS had done a lot of internal strategizing about how health homes would fit into care coordination before drafting it. The care coordination initiatives are examples of health homes and the ACA Health Home program had to fit with what the State was already doing. Giving care coordination time to develop before moving forward with health homes also allowed the State to see where existing programs needed enhancements in care coordination so they could use Health Homes to meet those needs. Additional funding under the federal program is only for 8 calendar quarters, so it is important to have to have a model ready on the front end. The goal is to submit a State Plan Amendment to implement health homes by the end of December. HFS Assistant Director Sharron Matthews offered context on the Health Home plan. 2

3 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 Health Homes are the next step to make care coordination work. They will create the capacity to provide the level of services for people who need intensive, ongoing support. Health Homes also open the door to community-based providers to work with networks that managed care entities have been building. Community-based providers should take note of where their services fit and how the Health Home concept facilitates partnerships. Summary of health home initiative Robert Mendonsa (see attached presentation) HFS Deputy Administrator for Care Coordination Robert Mendonsa described the concept paper in more detail. In drafting the paper, HFS consulted with other states and received technical assistance from federal CMS. HFS also discussed Health Homes with sister agencies, including the Division of Mental Health and Division of Alcoholism and Substance Abuse (DASA), and are meeting with the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) soon. The State plans to submit an application for Health Homes by the end of December 2014 with an expected October 1, 2015 effective date. Under Section 2703 of the ACA, Health Home services receive a 90% federal match for 8 quarters Role of Managed Care Entities Managed Care Entities (MCEs) will operate as Health Homes under the Illinois proposal, building on initiatives already in place. Health Home activity is already taking place within MCEs and the State can get an enhanced match on those existing Health Home services. What s missing in the MCE Health Home models is the capacity to serve high-risk clients. MCEs struggle to provide adequate community-based services for people with chronic conditions who are hard-to-reach. The Health Home initiative will prescribe policies, practices, and procedures and offer additional funding to MCEs to enhance capacity to serve those populations as Health Homes. Note that Care Coordination Entities were originally designed to target high-risk clients and Health Homes would learn from and build on that initiative. Health Home Eligibility (see slide 5 in attached presentation) Health Homes will have a defined eligible population. The proposal bases population criteria on the 3M Clinical Risk Groups algorithm, but it does not exclude any conditions categorically. The 3M software allows for objective criteria for all plans rather than asking each MCE to use its own methodology for identifying Health Home eligible members. The 3M CRG relies on claims, and Health Homes will need other data sources for people with no claims history (some ACA adults) 3

4 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 New York State is using 3M Clinical Risk Groups, with CMS approval. Stakeholders can look at the documents on New York s website to learn more about this tool. Health Home Services (see slides 6 and 7 in attached presentation) Section 2703 of the ACA requires six Health Home services (slide 6). Mr. Mendonsa highlighted the importance of comprehensive transitional care and additional investment needed to support referral to community and social support services. All the federal requirements for Health Homes are consistent with existing Illinois MCE contracts. Additional enhanced Health Home services for individuals who are especially high risk include more face-to-face home visits and lower care manager-to-member ratios. Health Homes will be expected to increase capacity for community-based mental health and substance use disorder service programs. The experience with managed care in Illinois is that there are a lot of enrollees who need these services and mental health and SUD services are areas where MCEs struggle the most. One reason is that people with serious mental illness and substance use disorders tend not to responds to telephonic intervention and need face-to-face engagement, which Health Homes will facilitate. Health Home Health Information Technology (HIT) Requirements See slide 8 in the attached presentation for specific requirements for real time clinical information sharing Mr. Mendonsa emphasized that when people are hard to find, it s especially important to know when they show up at ERs and engage them there when care managers have the opportunity. Payment (see slides 9 and 10 in attached presentation) Health Home services that MCEs provide now are paid for by capitation and care coordination fees, both per-member-per-month (PMPM) payments. Some MCE members care coordination costs more than the PMPM fee, some less. Health home eligible members likely generate more costs, and Illinois plans to cost allocate the PMPM rates and request enhanced Health Home match on the portion attributable to those eligible for health homes. The State would pay MCEs an additional PMPM fee to fund community-based Health Home services and to increase mental health and substance use disorder care management capacity. A quality withhold would apply specifically to the additional fee and MCEs could earn the withhold back by meeting enhanced care coordination quality measures. For example, plans are already held to quality measures on the percentage of care plans they complete for members and for Health Home members the plans may be held to a higher standard for that metric. Medical Loss Ratio (see slide 10): 4

5 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 The goal is to keep money in the system, but the State recognizes that MCEs will need to add resources to operate fully as Health Homes. For example CCEs will require additional oversight to meet Health Home requirement. The State therefore proposes a separate Health Homes MLR with the opportunity for MCEs to share savings if the MLR is below contractual targets. Monitoring and Evaluation: HFS Bureau of Quality Management Chief Jeff Todd (see slide 11 and pages of concept paper) Jeff Todd explained the quality measures and evaluation process for health homes. Section 2703 of the ACA outlines recommendations for quality measures, which Illinois is adopting. o o There are 26 adult core measures that CMS recommends for adult population 7 of the 8 fully developed measures in the concept paper are aligned with adult core measures. The same measures are being reported in other venues, creating less burden on providers. Illinois is also adding at least 2 additional measures that need further development (see page 15 of concept paper) o Percentage of total plan members with completed Health Risk Assessment o Percentage of eligible individuals with a person-centered care plan The proposed metrics are intended to hold Health Homes accountable and provide data so the State can meet federal reporting requirements An independent federal contractor will evaluate progress of the Illinois Health Home program, so there will be multiple levels of evaluation and accountability. Measuring cost savings To measure cost savings and how well care is managed, the State will measure potentially preventable readmission rates, Emergency Department utilization for Ambulatory Sensitive Conditions, and chronic health status Mr. Mendonsa pointed out that the State s priority for the Health Homes initiative is improving the quality of life for high-need individuals. Unmanaged transitions and unnecessary utilization of hospitals both wastes money and creates low quality of life. Therefore, improved care management can dramatically improve quality of life and save money. Timeframe: see slide 12 of the attached presentation Questions and comments: Kathye Gorosh, AIDS Foundation of Chicago, asked how the current Health Homes concept paper is aligned with the 1115 waiver application, which did specify that health homes would serve the HIV/AIDS population and didn t limit health homes to MCEs. Director Hamos responded that the State s policy is to not segregate people with certain illnesses into certain programs. To allow other, non-managed care entities to be Health Homes would require pulling Health Home-eligible individuals out of managed care effectively segregating based on illness. There is 5

6 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 a need for high-touch services in the community for high-risk individuals, and the approach in the concept paper incentivizes collaboration between MCEs and community-based providers to serve those individuals. It is collaboration that the proposal is pushing for and that has important promise beyond the two years of the federal initiative. The two years will be spent building partnerships (with additional funding) after which MCEs will understand the value of what the community-based, high-touch approach can produce. Assistant Director Matthews added that the Health Homes program would build capacity, and community-based organizations can have multiple Health Home contracts to expand their reach. Debbie Pavick, Thresholds noted, while recognizing the passion and intent behind the proposal, that many providers already consider themselves to be health homes for their specific population. She requested that the language in the concept paper be clearer about MCEs responsibility for creating Health Homes rather than simply being Health Homes themselves. (see Action Item below) She also asked how outstanding questions about how money flows will be resolved if they are not prescribed are the details up to the MCEs? In that case what does creating capacity and contracting with community providers mean? Mr. Mendonsa explained how the State expects the MCEs to coordinate with community-based providers. MCEs are already acting as Health Homes for a subset of the population today. Under this program, the State would identify MCE members who are eligible for the Health Homes by running MCE data through 3M software. Everyone at or above a given Clinical Risk Group level will be Health Home eligible and another sub-segment will be identified as high-risk within the health home eligible population. For that high risk population HFS will pay an enhanced capitation rate that MCEs have to spend on community-based services like those provided by Coordinated Care Entities and communitybased organizations. MCE and CCEs will report data to the state, and MCEs will have an incentive to coordinate with community-based providers to meet the goals the State sets that are attached to the quality withhold. Director Hamos added that Illinois already enrolled most Medicaid clients in MCEs and under Health Homes the State can get a higher match on the health home services already going on. New federal dollars should go to build capacity for community-based services. Ben Stortz, Cornerstone Services, pointed out that community-based providers are doing a lot of engagement with their clients already, but there is not a lot of contact with MCEs because the providers are handling and monitoring services for clients on their own. So we should be looking for more collaboration, and also consider that housing is a critical piece to community capacity building. Mr. Mendonsa responded that if community-based providers had all the data analytics that MCEs had and they could marry that technical capacity with their capacity to engage and serve clients, then that s the real deal. The goal of the program is to enhance what community providers are doing and invest more in that. Jan Gambach, Mental Health Centers of Central Illinois, said that community-based providers would appreciate merging the data side with the boots on the street, but questioned if there is a firm directive to MCEs to actually partner with community-based providers who are doing health home work. A 6

7 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 second issue she raised is the State s plan for the Excellence in Mental Health Act, which would create Certified Community Behavioral Health Clinics that are similar to Health Homes. Heather O Donnell, Thresholds, also spoke in favor of CCBHCs, suggesting that the State could use CCBHCs to pick up where this project leaves off and continue to receive enhanced federal match. Mr. Mendonsa emphasized that the Health Home proposal represents a change in strategy for managing MCEs. The State has not been prescriptive, focusing first on encouraging innovation. The Health Home plan is different because the State is making new money available but saying that it must go into community services. It also creates new incentives because MCEs keep some savings if they do what the State requires them to do with community providers. Assistant Director Matthews added that HFS is collaborating with DMH and DASA, planning for filling in gaps. Jeff Todd responded to the question about Certified Community Behavioral Health Clinics (CCBHC) that the State is meeting with SAMHSA and that if Illinois pursues CCBHCs, then the Federal government will look at what already exists in the state to avoid duplication and complement what s already there. Samantha Olds, Illinois Association of Medicaid Health Plans, suggested that the State look into what Missouri s Department of Public Health did to make real time data on ER use available to providers and plans. Mr. Todd agreed that we can learn from Missouri and other early implementers of health homes like Rhode Island. But Missouri targeted about 19,000 people with serious mental illness and Illinois is planning on going to scale more like North Carolina or New York with 300,000 people likely eligible. Director Hamos mentioned that the Admission-Discharge-Transfer alerts functionality that will be ready at the Illinois Health Information Exchange by the time Health Homes are up and running will make real time information sharing more feasible for more providers here. Assistant Director Matthews pointed out that the State wants to facilitate diversification and allow for smaller, more local providers to participate in care coordination. Tim Sheehan, Lutheran Social Services, inquired about areas of the state that don t have managed care and whether a non-managed care organization could contract to be a health home. Director Hamos suggested that this is a question that will be answered by the next administration, because the non-mandatory managed care areas of the state would be in a phase 2 of the Health Homes project. Amy Sagan, UI Health, noted that the 3M CRG software was used for children with medical complexity and asked if there is publicly available information to understand how risk stratification works in that software for the Health Home population. HFS responded that they do have that information and can share it with the subcommittee. Mr. Todd reminded the subcommittee that New York State used 3M for last year and a half and has public documents on their website (see for example, 7

8 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 Jan Gambach, Mental Health Centers of Central Illinois, said that New York and Missouri had made training and other supports available for organizations taking on the Health Home project and asked what Illinois plan is for training community-based providers. Director Hamos and Mr. Todd responded that the State plans to use the model for Accountable Care Entities and Coordinated Care Entities, but recognize that more will be needed and CMS will be looking for a robust training plan. Director Hamos suggested that the State will be much more prescriptive and have a uniform training program across MCEs, looking to other states training programs and borrowing from them. The Uniform Assessment Tool and common care plans should be part of the training process too. Eric Foster, Illinois Alcohol and Drug Dependency Association, said the language for the quality metric on initiation of AOD treatment on pages of the concept paper seems unclear. It refers to two or more inpatient admissions before treatment begins. Mr. Todd said that the concept paper should have used the exact HEDIS measure but they will check for a possible typo. (see Action Items below) Assistant Director Matthews added that HFS will be getting input from DASA and DMH on quality measures for mental health and substance use disorders, though Director Hamos pointed out that the Department hopes to have a narrow set of concrete measures that truly change provider practice rather than expanding beyond what is in other programs. Mr. Todd emphasized that quality measures must be aligned across programs. MCEs will be reporting in total 40 measures for ICP, 29 for ACEs those still get reported and the burden of reporting needs actually to drive improvement in quality to be justified. Art Jones, HMA, praised the concept paper for going beyond what the State had to do to get federal funds and drilling down to ensure care management at the community-level. He asked (1) if the 3M CRG threshold for Health Home eligibility had been defined and if it would rule out someone with just a serious mental illness and no other condition from qualifying, (2) if rates had been negotiated and if HFS will tier the rates by risk, and (3) how HFS will determine payment if people opt out. On the CRG level, Mr. Todd said that the thresholds they are looking at would catch someone with a single chronic condition including individuals with serious mental illness. (see Action Items list below) On tiered rates, Mr. Mendonsa said that HFS is working with Milliman to identify what they currently pay in capitation rates and what the additional rate will be. The current thinking is to add a flat amount to the capitation payment but restrict its use for the Health Home population only. MCEs could tier payments when they contract with community providers, however. On opt outs, Mr. Mendonsa explained that the option to opt out is a federal requirement, but they don t expect many people to exercise it. Margot Roethlisberger, Ada S. McKinley Community Services, asked if disability will be considered a chronic health condition for Health Home eligibility and how care management entities that Children s Services Subcommittee is recommending will they fit in to the Health Homes plan. Disability will be considered a chronic condition for Health Home eligibility. Director Hamos explained that the class action lawsuit, NB v Hamos requires a major re-design of the delivery system for children with mental illness. Most children in the class are already assigned to an MCE, so HFS has considered how MCEs fit into the consent decree. But the NB consent decree is going to take a year to develop and 8

9 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/ years to implement. As we implement different changes on different timelines we need to avoid duplicating care management services and identify which organizations are most capable in different contexts. Kathy Chan, Cook County Health and Hospital System, asked (1) how the 90% match on Home Health services for ACA adults works with the 100% match on all services for ACA adults and (2) how other states have kept Health Homes sustainable after the 8 quarters of enhanced match runs out. On the match differentials, Mr. Todd responded that the medical component of the fee paid to the Health Homes would be matched 100%, but the care coordination portion of the fee, which would mostly be matched at 50% now, would be matched up to 90% under the Health Homes proposal. On sustainability, Mr. Mendonsa suggested that before the enhanced match ended, MCEs would start comparing what they paid for community-based services and what they saved. If they save more than they pay, they ll continue and it will be sustainable. This project is all about proving that concept and gives community-based providers a chance to prove their value. Frank Anselmo, Community Behavioral Health Association, asked about the timeframe for input on the concept paper (see Next Steps below) and suggested that a lessons learned for the State Plan Amendment is to include flexibility to expand into new categories, such as primary behavioral health care initiatives and systems of care projects. Carol Robert, BCBS, asked if the State expects to contract with new MCEs. Mr. Medonsa responded that they will use existing CCEs and also establish criteria to identify CCE-like organizations as well. Sonia Bhagwakar, Illinois Department on Aging, asked if HFS is using only existing claims data to determine eligibility. If clients are in the system, they will use claims data, if, like some ACA adults, clients don t have a claims history, they will use the health risk assessment process to identify eligible individuals. Tim Sheehan, Lutheran Social Services, asked if 100% of the Health Home dollars go through MCOs. Director Hamos responded that MCOs, ACEs, and MCCNs will all operate as Health Homes, and that HFS is not contracting with CCEs as Health Homes because their per-member-per-month rate is already much higher. The growth potential for CCEs was always thought to be in contracting with MCOs, which they will have more opportunity to do under the Health Homes proposal. Patrick Gallagher, Illinois Hospital Association, asked if the quality measures for Health Homes are already reported in the Integrated Care Program. Mr. Todd said that the quality metrics in the concept paper will be specifically for the Health Home population. Where they are aligned with the ICP, HFS will have the data and will just need to identify Health Home members. There is already a great deal of alignment and HFS can identify where the Health Home metrics are aligned and where they are new (see Action Items below). 9

10 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/2014 Kathye Gorosh, AIDS Foundation of Chicago, mentioned that the Quality Metrics subcommittee had considered special sub-populations like people who are homeless, while the measures in the Health Homes concept paper are missing the sorts of things community-based providers do for those populations that would show value. Mr. Todd clarified that the Health Home quality metrics are intended to measure performance on care coordination, not to measure health outcomes. The Health Home metrics are nationally validated with national stewards, which makes them far more reliable than metrics that we might invent for the program. HFS will also be looking at medical status and will weight metrics within categories and measure over time to monitor performance more granularly. Michaal Gelder noted that the Integrated Delivery System subcommittee s work emphasized bringing care management down to the primary care practice level, eliminating the fragmentation in the handoff from the PCP office to a care management call center. He asked how that framework fits into the Health Homes concept. Mr. Mendonsa said that the weak link between the care manager and the PCP in MCOs today and the much stronger linkage within in the CCEs is something the Health Homes need to learn from to create true engagement of the PCP office within the care team. Gelder suggested that the concept paper needs to say that to avoid seeming like we re creating a new silo of care management. (see Action Steps below) Sherie Arriazola, TASC, asked if Illinois is considering targeting people in the justice-involved population who have chronic conditions, especially mental illness and substance use disorders. People who are discharged from correctional facilities need to be connected to specialized providers with experience caring for this population. Assistant Director Matthews responded that HFS is working with TASC, the Illinois Department of Corrections, and the Cook County Jail on improving access to post-release services. HFS can identify expectations for MCEs when negotiating with CBOs like TASC that could bring value to Health Homes serving the justice-involved population. Director Hamos affirmed that involvement in the justice system does create distinct needs, but what that means for care coordination is a challenging question, and the 3M software won t flag individuals as justice-involved but as having one or more chronic conditions, complicating targeting. C. NEXT STEPS, Michael Gelder o o o o GOHIT plans to present the Health Homes proposal as a recommendation from the IDSR workgroup More feedback is encouraged, but the recommendations for final GOHIT report are due by December 15, so the subcommittee s deadine for Health Home comments is Friday, December 5. Send comments to Gov.IDSR.GOHIT@Illinois.gov HFS will post Q&As on website 10

11 Governor s Office of Health Innovation and Transformation Integrated Delivery System (IDS) Subcommittee Meeting Minutes 11/26/ MEETING END Meeting Scheduled End: 11:30AM Meeting Actual End: 11:45AM 6. SUMMARY OF ACTION ITEMS Action Assigned To Deadline Clarify language in concept paper about MCEs responsibility for creating health homes in partnerships with community providers to avoid perception that MCEs will exclusively be health homes themselves. Check quality metric on initiation of AOD treatment for typo in requirement for at least two inpatient admissions Clarify that an individual with a serious mental illness and no other chronic condition would be eligible for Health Home services (see federal statute language, for example) Identify which quality metrics are new and which are aligned with ACE and ICP reporting. Clarify that Health Homes require practice-level linkages between care managers and primary care physicians, not the creation of new care management silos. 7. DECISIONS MADE N/A 8. NEXT MEETING 11

12 DRAFT Health Home Concept Paper 1. How are health home services provided? Illinois Medicaid has been primarily a fee-for-service system, involving thousands of healthcare providers who have provided invaluable healthcare services and social supports to low-income individuals and families for many years. Aligned with national healthcare reform, the State of Illinois has embraced the vision of the Triple Aims: improving the experience of care, improving the health of populations, and reducing the growth in health care costs. To accomplish the Triple Aims, Illinois Medicaid is in the process of implementing a redesign of the Medicaid healthcare delivery system. This ambitious redesign will move Illinois from a fundamentally fee-for- service system to a system that aggressively promotes care coordination, payment reform and health outcomes. The new system incentivizes providers, community-based organizations, and traditional managed care organizations to work together to coordinate care and improve the experience and quality of care received by Illinois Medicaid clients. Illinois is unique in the nation with the development of innovative Managed Care Entity (MCE) models: Care Coordination Entities (CCE): CCEs are a collaboration of providers and community agencies, governed by a lead entity that receives a care coordination payment in order to provide care coordination services for its enrollees (medical services are still fee-for-service). A CCE may serve Seniors and Persons with Disabilities or Children with Special Needs. A CCE must have a network of providers and community partners who shall deliver coordinated quality care across provider and community settings to Enrollees. The Enrollee shall be at the center of the CCE s coordinated care network and delivery system. The CCE shall coordinate care across the spectrum of the healthcare system with emphasis on managing transitions between levels of care and coordination with community and social services. CCEs are eligible to share in Medicaid savings pursuant to the State Plan (state plan amendment currently under CMS review) provided that it meets quality measure targets. Managed Care Community Networks (MCCN): A MCCN is an entity, other than a Health Maintenance Organization, that is owned, operated, or governed by providers of health care services within Illinois and that provides primary, secondary and tertiary managed health care services under a riskbased capitation arrangement. MCCNs are subject to aggressive care coordination contract standards that require assignment of an interdisciplinary care team of health professionals to Enrollees. The interdisciplinary care team must coordinate care across the continuum of the healthcare system and with community and social service organizations to 11/24/14 1

13 ensure the Enrollee is at the center of the delivery system. MCCNs are monitored and eligible for incentive payments for meeting quality measures. MCCNs may serve individuals enrolled in all eligibility categories (SPD, FHP, ACA Expansion, etc.). Managed Care Organizations (MCO): MCOs operating in Illinois provide the full range of Medicaid services under a capitated payment arrangement. MCOs must be recognized by the Illinois Department of Insurance. MCOs are subject to aggressive care coordination contract standards that require assignment of an interdisciplinary care team of health professionals to Enrollees. The interdisciplinary care team must coordinate care across the continuum of the healthcare system and with community and social service organizations to ensure the Enrollee is at the center of the delivery system. MCOs are monitored and paid according quality measures. MCOs serve individuals enrolled in all eligibility categories. Accountable Care Entities: An ACE is an organization comprised of and governed by its participating providers, with a legally responsible lead entity, that receives a care coordination payment to coordinate the care of its Enrollees (medical services are still fee-for-service for the first 18 months, and take on financial risk thereafter), and is accountable for the quality, cost, and overall care of its Enrollees. An ACE cannot be an insurance plan. The ACE demonstrates an integrated delivery system, shares clinical information in a timely manner, and designs and implements a model of care and financial management structure that promotes provider accountability, quality improvement, and improved health outcomes. ACEs are eligible to share in Medicaid savings pursuant to the State Plan (state plan amendment currently under CMS review) provided that it meets quality measure targets. ACEs generally serve children, families, pregnant women, and newly eligible ACA Adults. The Illinois Health Home program builds on its redesigned delivery system and leverages the infrastructure and the strong care coordination models already in place within the Managed Care Entities (CCE, MCCN, MCO, and ACE) networks. Individuals eligible for Health Homes will be defined by the State. Eligible individuals will be provided Health Home services by the Managed Care Entity (Health Home), which they are enrolled for the provision of Medicaid services and/or care coordination services under the redesigned Medicaid delivery system in Illinois. In the five mandatory managed care regions, eligible individuals will have the option to refuse health home services at any time. In addition, Enrollees have the option to switch Health Homes within 90 days of enrollment into the Health Home and the opportunity to switch Health Homes at their annual open enrollment. In a voluntary managed care county, Enrollees may opt out of the Health Home or switch Health Homes on a month-to-month basis. 11/24/14 2

14 2. Geography Health Homes will operate in the following service areas: a. Greater Chicago (including Cook and 5 collar counties) b. Rockford (tier of 3 northern Illinois counties) c. Quad Cities (3 counties in the Rock Island-Moline area) d. Central Illinois (15 county region including cities of Springfield, Bloomington, Campaign, and Peoria) e. Metro East (3 Illinois counties in St. Louis area) f. Specified Voluntary Counties 3. Population Criteria The State will provide health home services to individuals with: Two Chronic Conditions One chronic condition and at risk for developing another Chronic conditions include: o Mental Health condition o Substance Abuse o Asthma o Diabetes o Heart Disease o BMI over 25, at which time data is available o Other chronic conditions: Illinois will provide health home services to individuals in the major categories described above, as identified through the 3M Clinical Risk Grouping software. The State will identify Medicaid clients enrolled in a MCE and who have a specific CRG score or higher as Health Home enrollees. Individuals will receive health home services for a period of eight quarters at which time the State will reassess their CRG score. The State will further identify higher risk individuals using CRGs who will require enhanced health home services. Health Home services will be provided to all categorically eligible Medicaid recipients including children, dual eligible, and waiver participants. The State plans to implement health homes on July 1, Provider Infrastructure Health Homes will be a designated provider as defined in Section 1945(h)(5) of the Act. The designated provider will work with a multi-disciplinary team of health care professionals including representation from the medical, behavioral health, social and community service, and, as applicable, long-term care sectors to provide health home 11/24/14 3

15 services. The team of health care professionals will include physicians and other professionals such as a nurse practitioner, nutritionist, social worker, behavioral health professional, peer support specialist, outreach worker, pharmacist, or a HCBS waiver case manager. The designated provider will be the Managed Care Entity. Entities eligible to become health homes in Illinois are the Managed Care Entities and include MCOs, MCCNs, CCEs, and ACEs. The designated provider will assign a team of health care professionals to work together under a formal agreement and agreed upon care coordination protocols to offer health home services as defined by the State. The delivery of health home services will be lead by a designated care manager who will assure that enrollees receive medical, behavioral health, and social services under a single care plan, agreed upon among the team of health professionals. The care manager will be responsible for monitoring the care plan and ensuring goals are updated, as necessary. The State will provide initial and ongoing to training and technical assistance to the MCEs (Health Homes). 5. Service Definitions a. Comprehensive Care Management must include: i. Individualized Care Plan. For all Health Home Enrollees, Health Homes must provide an individualized, person-centered care plan developed based upon a comprehensive health risk and, if necessary, behavioral health risk assessment. The care plan must integrate an Enrollee s medical, behavioral health, long-term care, rehabilitative and social service needs, as appropriate. The care plan must clearly identify the primary care physician and any other providers involved in delivering care to the Enrollee as well as community networks and social supports. The care plan must include goals, timeframes, and action steps towards improving the Enrollee s overall health. The Enrollee must be an active participant in the development of the care plan. The care team will be required to play an integral role in the creation, monitoring, and updating of the care plan. The care team is the patient advocate and primary resource for both medical and social multidisciplinary communication. ii. Integration of physical and behavioral health. Health Homes will provide integrated physical and behavioral health services as appropriate to the Enrollees needs. Screenings for intimate partner violence, depression, and substance abuse should be part of the initial assessment. Enrollees should be screened using validated tools with appropriate and timely follow up and referrals. Inpatient and outpatient behavioral health treatment plans should be incorporated in the overall care plan. 11/24/14 4

16 iii. Family involvement. Health Homes must provide the opportunity for family and/or caregiver involvement based on the Enrollee s preference. This includes the development, monitoring and updating of the care plan, according to the Enrollee s needs and wishes. iv. Tracking care plan goals. The care manager will be responsible for monitoring and tracking care plan goals, and working with the team of health professionals to update goals and interventions as necessary. v. Mental health and substance abuse screenings. The Health Home must complete an initial screen for behavioral health issues within a specified period of time after enrollment, and complete a further comprehensive assessment, if indicated in the initial screen. vi. Periodic reassessment. Health Homes must periodically reassess an Enrollee s needs and update care plans as dictated in the MCE contracts or as needed based on changes in health status. vii. Care Manager to Enrollee Ratios. Health Homes must have Care Manager to Enrollee Ratios appropriate to need. viii. Integration of Housing Services. The Health Home must work with community organizations that provide supportive housing or other services related to homelessness or tenancy service. ix. For health home eligible individuals the State identifies as high-risk, the Health Homes will be required to have smaller care manager to enrollee ratios. b. Care Coordination must include: i. Adherence to treatment / medication monitoring. The care manager is responsible for coordinating all necessary care and monitoring Enrollee adherence to the care plan, which includes medication monitoring. The Health Home must assure defined responsibilities among each health home team member and foster communication between the care manager and the members of the health home such as the treating clinicians to discuss the enrollee s needs. The health home must have defined accountabilities in place to assure effective collaboration among the health home members. 11/24/14 5

17 ii. Referral tracking. The Health Home must develop and/or utilize a system to share regularly updated clinical information and track referrals and care needs across providers, preferably using Certified Electronic Health Record Technology (CEHRT), meeting ONC Meaningful Use criteria and PCMH standards. iii. Emphasis on face-to-face contacts. The Health Home must have policies and procedures in place to ensure care managers engage in regular face-to-face contact with enrollees. iv. Use of case conferences. The Health Home must have policies and procedures in place to ensure regular case reviews with all members of the care team. v. Tracking test results. The Health Home must have systems in place to track test results and ensure those results are accessible to all members of the care team. vi. Requiring discharge or transition of care summaries. The Health Home will require use of discharge summaries that are incorporated into the care plan and accessible to all members of the care team, preferably using CEHRT and HIE. vii. Automated notification of admission. The Health Home will develop a system to notify care team members when an Enrollee is discharged from the ED or is admitted to a hospital. viii. Housing coordination. Health homes will provide housing coordination assistance as necessary. ix. For high-risk enrollees identified as needing enhanced Health Home services, the Health Home must ensure regular face-to-face contact between the care manager and enrollee as appropriate to coordinate the enrollee s care. The State also encourages health homes to perform a home visit from someone from the care team during the development of the care plan, and periodic home visits in order to monitor and update care plans. c. Health Promotion must include: i. Development of self-management plans through the individualized care plan and the referral to needed resources such 11/24/14 6

18 as smoking cessation, self-help recovery, or management of chronic diseases. ii. Evidence-based wellness and promotion through enrollee health education via methods such as one on one teaching, group therapy, and peer support. iii. Culturally, linguistically and age appropriate educational resources to encourage patient engagement, family/caregiver involvement, and self-health improvement or maintenance. d. Comprehensive Transitional Care will be provided to prevent readmission and to ensure appropriate and timely follow up after discharge. Health homes must ensure: i. Notification of admissions/discharge. The Health Home must have policies, procedures, and relationships in place with hospitals and residential and rehabilitation facilities to ensure prompt notification to the care manager of admission or planned discharge of an Enrollee. ii. Receipt of summary care record. The Health Home will develop and utilize a follow-up protocol to assure timely access to followup care post-discharge that includes at a minimum, medication reconciliation, pharmacist coordination, home health nursing, if applicable, and a plan for timely scheduled appointment at outpatient providers preferably transmitted using CCDA (Consolidated Clinical Document Architecture) compliant protocols. iii. Specialized transitions (age- related, corrections). The Health Home must have policies and procedures in place with local practitioners including emergency departments, hospitals, and community-based providers to ensure safe transportation for enrollees who require it especially those who require transfer between sites of care. iv. For high-risk enrollees identified as needing enhanced Health Home services, the State encourages Health Homes to require the care manager to be present at discharge from any level of care and make a timely home visit upon an inpatient or ED discharge. e. Individual and Family Support Services. The Health Home must ensure: 11/24/14 7

19 i. Use of support groups and self-care programs to facilitate improved self-management of conditions and improved adherence to treatment. ii. Reflection of the Enrollee and family or caregiver preferences in the care plan. iii. Communication is culturally and linguistically appropriate. iv. Enrollees, families, and caregivers are provided information on the use of advance directives and end of life wishes are discussed and documented if applicable. v. Family/caregivers are involved with patient centered plans including peer supports if applicable. vi. Assistance with attaining highest level of functioning in the community. vii. Encouraging home and community based service integration by maximizing social supports with Enrollee s preferred networks. f. Referral to Community and Social Support Services. The Health Home will actively identify community-based resources and manage appropriate referrals to community-based resources including follow-up. The Health Home will place an emphasis on identifying resources closest to home and least restrictive. The Health Home may also consider developing a resource manual. The Health Home must have policies, procedures, and accountabilities with community-based organizations to ensure effective collaborations and coordination of care. g. The Way HIT will link services. Health Homes will be required to utilize CEHRT and HIE as feasible to improve service delivery and coordinate care across the continuum. Health Homes must have policies and procedures in place that allow members of a care team to securely share clinical information, track referrals and to access to a single care plan. Health Homes are encouraged to use CCDA compliant HIT to provide notification to care team members of ED and inpatient hospital admissions. The State understands that some providers in a Health Home network may not utilize HIT. As such, the State encourages MCOs, MCCNs, CCEs (and requires ACEs) to utilize the Illinois Health Information Exchange (ILHIE). Utilization of the ILHIE will allow care team members to securely share clinical information. 6. Provider Standards. In Illinois, a Health Home provider is the central point in coordinating an Enrollee s care including medical, behavioral, and social need. A Health Home provider is responsible for reducing preventable inpatient admission/readmissions; preventing 11/24/14 8

20 avoidable ED visits; improving quality outcomes while reducing overall per capita cost. A Health Home provider must: Be enrolled in the Illinois Medicaid program and comply with all program requirements. Be capable of providing or contracting for the provision of all Health Home services required in its contract. The Health Home is ultimately responsible for all subcontracted activities. Include hospitals in its network and have policies and procedures in place to refer any Health Home Enrollee who seeks or needs treatment in a hospital ED to the appropriate outpatient provider and to include the care manager in the referral process. Have policies and procedures in place that passes a readiness review by the State s EQRO to provide all required Health Home services described in Section 5, Service Definitions. 7. Payment. The State, in its redesigned delivery system, has created Health Homes in each type of Managed Care Entity (MCEs). All MCEs are essentially responsible for the overall quality and cost of care delivered and must implement similar health home service requirements. Taking into consideration that all MCEs are Health Homes, the State proposes the following payment methodologies. a. MCOs/MCCNs: The MCOs and MCCNs operate under a risk-based payment arrangement. A portion of the capitation payment (care coordination component) is designed to cover the provision of the contractual health home services. Because not all Enrollees in a MCO or MCCN will be identified as health home eligible, the State proposes to cost allocate the care coordination component included in the capitation rates for all beneficiaries and attribute more of the care coordination fees to the health home populations. The State is requesting 90 percent match on the cost allocated amounts to health home beneficiaries. This proposal is based on the fact that MCOs and MCCNs will spend more of the care coordination component of the capitation rate on providing health home services to health home populations. The State s actuary will be engaged to complete this analysis. All MCEs will be monitored by the State and its EQRO to assure Health Home eligible enrollees receive the robust level of care coordination they need and the Plan is contractually required to provide. The MCO and MCCN contracts include a per member per month withhold from the capitation payment that MCOs and MCCNs can earn for meeting quality measure targets. This withhold is an incentive for Health Homes to provide the robust level of care coordination required to improve quality outcomes. For the high-risk Health Home populations, MCOs and MCCNs will be required to provide additional services beyond what is currently assumed in 11/24/14 9

21 the capitation rates. As such, the State proposes to pay an additional fee to the MCOs and MCCNs for the provision of high-risk health home services. The State will request 90 percent match on this additional fee. The additional fees will be allocated across all beneficiaries enrolled in the MCE. The State will withhold a percentage of the additional fees that the MCEs can earn back for performing required care coordination activities that the State will monitor through quarterly reporting and encounter data (e.g. meeting care plan completion targets). Furthermore, the State will include a separate MLR requirement for the additional fee. To provide MCOs and MCCNs with an incentive to offer the additional health home services, MCOs and MCCNs will have the opportunity to share in the difference between the actual and contractual MLR and to reinvest savings in areas to improve overall health. The retained amount would be capped (i.e. 3 percent) and tiered. b. ACEs. ACEs currently receive a flat care coordination fee for all Enrollees regardless of whether the individual is Health Home eligible. Similar to the proposal above, because the majority of care coordination activity will be provided to Health Home eligible individuals, the State proposes to cost allocate the care coordination fees for all beneficiaries and attribute more of the care coordination fees to the health home populations. The State will request 90 percent match on the cost allocated amounts attributed to health home beneficiaries. ACEs are eligible to receive shared savings payments for meeting certain quality measure targets. Shared savings is an incentive for the ACEs to implement the robust level of required Health Home services. For high-risk Health Home populations, the State proposes to provide an additional fee to the ACEs for the enhanced health home services not assumed in the original care coordination fee. The State will request 90 percent match on this additional fee. The additional fees will be allocated across all beneficiaries enrolled in the ACE. The State will withhold a percentage of the additional fees that the ACEs can earn back for performing required care coordination activities that the State will monitor through quarterly reporting and encounter data (e.g. meeting care plan completion targets). c. CCEs. The CCEs generally serve Seniors and Persons with Disabilities with greater care needs or Children with Special Needs and have smaller enrollments. CCEs currently receive a flat care coordination fee for all Enrollees. The CCE care coordination fees assume all levels of health home services including those high-touch services required for the high-risk Health Home individuals. Because the majority of care coordination activity will be provided to Health Home eligible individuals, the State proposes to cost allocate the care coordination fees for all beneficiaries and attribute more of the care coordination fees to the Health Home populations. The State will 11/24/14 10

22 request 90 percent match on the cost allocated amounts attributed to Health Home beneficiaries. CCEs are eligible to receive shared savings payments for meeting certain quality measure targets. Shared savings is an incentive for the CCEs to implement the robust level of required Health Home services. 8. Monitoring. Below are the methodologies the State will use to monitor avoidable hospital readmissions and for calculating cost savings. Please note that because Health Homes are integral to the MCE structure, the State cannot identify Health Home outcomes and savings separately. a. Tracking avoidable hospital readmissions. To be provided at a later date. b. Method for calculating cost savings. To be provided at a later date. 9. Evaluations. a. Hospital Admission Rates. The State will collect encounter data to monitor hospital admission rates. b. Chronic Disease Management. The State will monitor chronic disease management through contractually defined quality measures. c. Coordination of Care for Individuals with Chronic Conditions. The State will monitor coordination of care for individuals with chronic conditions through quality measures, encounter data, and regular reporting of care coordination activities. d. Assessment of Program Implementation. The State will monitor program implementation through regular meetings with the MCEs, and quarterly and annual reporting. e. Processes and Lessons Learned. The State will monitor program implementation and identify processes and lessons learned through regular meetings with the MCEs, quarterly and annual reporting, and regular stakeholder meetings. f. Assessments of Quality Improvements and Clinical Outcomes. The State will monitor assessments of quality improvements and clinical outcomes through its Bureau of Quality Managements and contractually defined quality measures. g. Estimates of Cost Savings. To be provided at a later date. 11/24/14 11

23 10. Quality Measures. The table below depicts the quality measures the State will use to monitor Health Homes. NQF # N/A N/A Measure Title Measure Description Numerator/Denominator Alignment with Other CMS Program Measures 1. Adult Body Mass Index (BMI) Assessment 2. Ambulatory Care-Sensitive Condition Admission Care Transition Transition Record Transmitted to Health Care Professional Percentage of members years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior to the measurement year. Ambulatory care sensitive conditions: age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. Care transitions: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary care physician or other health care professional designated for follow-up care within 24 hours of discharge. Numerator Description: Body mass index documented during the measurement year or the year prior to the measurement year. Denominator Description: Member years of age who had an outpatient visit. Numerator Description: Total number of acute care hospitalizations for ambulatory care sensitive conditions under the age of 75 years. Denominator Description: Total mid-year population under 75 years. Numerator Description: Patient for whom a transition record was transmitted to the facility or primary care physician or other health care professional designated for follow-up care within 24 hours of discharge. Denominator Description: All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or Medicaid Adult Core Set, HEDIS Medicaid Adult Core Set. 11/24/14 12

24 Follow-up After Hospitalization for Mental Illness Plan- All Cause Readmission Screening for Clinical depression and Follow-up Plan Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge. For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Percentage of patients aged 18 years and older screened for clinical depression using a standardized toll AND followup documented. rehabilitation facility) to home/self-care or any other site of care. Numerator Description: An outpatient visit, intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days after discharge. Include outpatient visits, intensive outpatient encounters or partial hospitalizations that occur on the date of discharge. Denominator Description: Members 6 years of age and older discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal mental health diagnosis on or between January 1 and December 31 of the measurement year. Numerator Description: County the number of Index Hospital Stays with a readmission within 30 days for each age, gender, and total combination. Denominator Description: Count the number of Index Hospital Stays for each age, gender, and total combination. Numerator Description: Total number of patients from the denominator who have follow-up documentation. Denominator Description: All patients 18 years and older screened for clinical depression using a standardized tool. Children s Core Set, Medicaid Adult Core Set, HEDIS Medicaid Adult Core Set, HEDIS PQRS, CMS QIP, Medicare Shared Savings Program, Medicaid Adult Core Set, Meaningful Use Stage Initiation Percentage of adolescent and Numerator Description: Meaningful Use Stages 11/24/14 13

25 and Engagement of Alcohol and Other drug Dependence Treatment adult members with a new episode of alcohol or other drug (AOD) dependence who received the following: Initiation of AOD treatment. Engagement of AOD treatment Initiation of AOD Dependence Treatment: Members with initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of diagnosis. Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters, or partial hospitalizations with any AOD diagnosis within 30 days after the date of Initiation encounter (inclusive). Multiple engagement visits may occur on the same day, but they must be with different providers in order to be counted. 1 and 2, Medicaid Adult Core Set, HEDIS Controlling High Blood Pressure The percentage of patients years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. Denominator Description: Members 13 years of age and older as of December 31 of the measurement year with a new episode of AOD during the intake period, reported in two age stratifications (13-17 years, 18+ years) and the total rate. The total rate is the sum of the two numerators divided by the sum of the twp denominators. Numerator Description: The number of patients in the denominator whose most recent, representative BP is adequately controlled during the measurement year. For a member s BP to be controlled, both the systolic and diastolic BP must be < 140/90mm Hg. Denominator Description: Patients with hypertension. A patient is considered hypertensive if there is at least one outpatient encounter with a diagnosis of HTN Million Hearts, Medicaid Adult Core Set, Meaningful Use Stage 2, ACO Measure. 11/24/14 14

26 Percent of members in the Plan who had a Health Risk Assessment completed within days of auto-assignment or enrollment; percentage of members determined Health Home eligible via HRA who had a person-centered care plan developed and in place within days of Health Home eligibility determination. Percent of Health Home Eligible persons identified by HFS through 3M-CRG stratification who have a person-centered care plan developed and in place within days of Health Home eligibility notification of the Plan. during the first six months of the measurement year. 11/24/14 15

27 Health Homes Initiative Wednesday, November 26, 2014 Robert Mendonsa, HFS Deputy Administrator Jeffrey Todd, HFS Chief of Bureau of Quality Management 1