Citizen Budget Commission Special Event New York State Health Home Program. May
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1 Citizen Budget Commission Special Event New York State Health Home Program May
2 May What is a Health Home? Health Homes are a care management model, authorized under the Affordable Care Act (ACA) that provide intensive care management for Medicaid members that have chronic conditions. These Medicaid members are typically high need/ high cost member NYS implemented Health Homes in 2012 transitioning targeted case management into Health Home networks designated regionally Health Home care managers, in concert with a multi-disciplinary team of providers (Health Home network), and managed care plans, develop and help implement person-centered, integrated care plans (i.e., physical health, behavioral health, community and social supports)
3 May What is a Health Home? 33 Health Homes (HHs) provide access to Health Home care management in all 62 counties of the State 17 serve adults only 13 serve adults and children 3 serve children only
4 4 New York State Health Home Model
5 5 Health Home Enrollment By Member s County and Age Group COUNTY AGES 0 TO 20 AGES 21 AND OVER GRAND TOTAL NEW YORK CITY 6,514 80,914 87,428 ERIE 1,518 14,472 15,990 MONROE 939 8,568 9,507 SUFFOLK 576 8,699 9,275 WESTCHESTER 459 5,375 5,834 NIAGARA 475 4,520 4,995 ONONDAGA 612 3,703 4,315 NASSAU 205 3,963 4,168 DUTCHESS 229 2,153 2,382 BROOME 241 2,107 2,348 ORANGE 97 2,047 2,144 ONEIDA 198 1,932 2,130 CHAUTAUQUA 255 1,494 1,749 SCHENECTADY 144 1,554 1,698 JEFFERSON 243 1,290 1,533 ALBANY 138 1,305 1,443 RENSSELAER ,068 OSWEGO ST LAWRENCE ROCKLAND COUNTY AGES 0 TO 20 AGES 21 AND OVER GRAND TOTAL ULSTER STEUBEN ONTARIO CATTARAUGUS CLINTON SULLIVAN CAYUGA WAYNE WARREN SARATOGA MONTGOMERY CHEMUNG FRANKLIN WASHINGTON CHENANGO COLUMBIA MADISON GREENE TOMPKINS OTSEGO COUNTY AGES 0 TO 20 AGES 21 AND OVER GRAND TOTAL HERKIMER DELAWARE FULTON ALLEGANY ESSEX LEWIS SENECA LIVINGSTON SCHOHARIE CORTLAND TIOGA PUTNAM GENESEE ORLEANS WYOMING YATES SCHUYLER HAMILTON TOTAL 15, , ,002 (February 2018 Health Home Enrollment Data)
6 Health Home Enrollment Feb vs. Feb Adult and Children Health Home Enrollment February ,002 vs. February ,177 6
7 Health Home Members have Significant Chronic Conditions (SMI, HIV, Multiple Chronic Conditions) 7 Chronic Condition Group # of Health Home Enrollees HIV 23,190 HARP (not HIV) 30, Chronic Conditions (No HARP or HIV) Other SMI (not HIV, not HARP, and Not 2+ Chronic Conditions) 84,678 16,747 Members with Health Home eligible conditions can be difficult to engage HARP members have significant behavioral health needs (mental health or substance abuse) 45% of Enrollees have SMI, are HARP, or HIV (single qualifying condition for HH)
8 8 Performance Management Implemented Technical Assistance and Quality Monitoring for all Health Homes in response to Health Home site survey findings- four Health Homes have been closed since launch one was closed in March 2018 Began Site Surveys for Health Home Serving Children launched in 2016 Implemented Performance Management Program Issuing Health Home Measures and Specifications and Reporting Manual Established Performance Goals and Annual Improvement Targets Finalizing Health Home Performance Report Card for CY 2016 data on: Enrollment HARP Conversion Rate Member Medicaid Cost (PMPM) and Change in Preventable Cost PMPM Retention (for at least six months) Avoidable Utilization Composite Score Quality Composite Score Structural Measures
9 9 Performance Management Composite Scorecard HH Information Enrollment Cost Retention Performance Measure Composite Score Structural Measures Score Weighting Factor (%) 0% 15% 0% 0% 15% 15% 25% 5% 15% 10% 100% Health Home Number of Enrolled Members HARP Conversion Rate Medicaid Cost for Enrolled HH Members (PMPM) Change in Preventable Utilization Cost (PMPM) Retention Rate Composite Score for Preventable Utilization (PPV and PPR) (CY 2016) Composite score of RD Site visit remaining HH measures (CY level 2016) Billing Accuracy HHDF Use Summary Score Adirondack Health Institute Bronx Accountable Bronx Lebanon Capital Region Health Connections Care Central Central New York Health Home Community Care Management Partners Community Healthcare Network Coordinated Behavioral Care Encompass Greater Buffalo United IPA Greater Rochester Health Home Network Health Home Partners of Western NY HHUNY Central (Circare) HHUNY Finger Lakes (Huther-Doyle) HHUNY Southern Tier (Chautaugua County) HHUNY Western (BestSelf) Hudson River HealthCare Hudson Valley Care Coalition Institute for Family Health Mary Imogene Bassett Community Health Navigation New York City Health and Hospitals Corporation New York Presbyterian Niagara Falls Northwell Health Queens Coordinated Care Partners Southwest Brooklyn Health Home St. Joseph's Care Coordination Network St. Luke's St. Mary's Healthcare United Health Services
10 10 Performance Management Annual Measurement Year Cycle Time Frame HH Performance rates/results released to HHs January 2018 Health Home Performance Goals released to HHs January 2018 Annual Improvement Targets for 2018 calculated and released to HHs January 2018 January June 2017 Performance results released May 2018 Health Home Performance Report Card released to HHs June 2018 June August 2017 Performance results released June 2018 Annual Performance Review (2017 Measurement Year) July 2018 Annual Performance Report Card and Review Results released August 2018 Annual Improvement Targets for 2019 calculated and released to HHs September 2018
11 Health Homes Improving Quality of Care for Enrolled Members % increase in rate from 2013 to % increase in rate from 2013 to % increase in rate from 2013 to 2016 Measure Includes Adult Members 21 and Older Measure Rate Higher rate is better
12 Health Homes Reducing and Avoiding High Cost Acute Care % reduction in rate from 2014 to % reduction in rate from 2014 to 2016 Measure Includes Adult Members 21 and Older Lower rate is better Measure Rate
13 Health Homes Reducing Inpatient Admissions % reduction in rate from 2014 to % reduction in rate from 2014 to 2016 Measure Includes Adult Members 21 and Older Lower rate is better Measure Rate
14 Health Homes Improving Potentially Preventable Readmissions Rates (PPR) 14 Potentially Preventable Readmissions: The total number of potentially preventable readmission chains per 100,000 enrollees 83.33% of Health Homes improved PPR Rates between 2014 and 2016 Measure Includes Adult Members 21 and Older Lower rate is better Measure Rate
15 Health Homes Improving Potentially Preventable ER Visits Rates (PPV) 15 Potentially Preventable Emergency Room Visits: The total number of potentially preventable emergency visits for ambulatory sensitive conditions per 100 enrollees 90.32% of Health Homes improved PPV rates between 2014 and 2016 Measure Includes Adult Members 21 and Older Lower rate is better Measure Rate
16 Health Homes Improving Comprehensive Diabetes Care Rates (CDC) 16 Comprehensive Diabetes Care: 79.17% of Health Homes improved CDC rates between 2013 and 2016 The percent of members with diabetes who received at least one Hemoglobin A1c (HbA1c) test within the year Measure Includes Adult Members 21 and Older Measure Rate Higher rate is better
17 Health Homes Improving Follow-up after Hospitalization for Mental Illness within 30 days Rates (FUH) 17 Follow-up after Hospitalization for Mental Illness within 30 days: 65.22% of Health Homes improved FUH rates between 2013 and 2016 The percent of discharges for members who were seen on an ambulatory basis or who were in intermediate treatment with a mental health provider within 30 days of discharge Measure Includes Adult Members 21 and Older Measure Rate Higher rate is better
18 Cohort PMPM Costs: Cost shift over time Waterfall chart showing incremental change in total cohort PMPM by service mix from the period immediately prior to enrollment through the end of the analysis period 18 Inpatient and ED down Pharmacy, Ambulatory Care and Transportation Up showing positive change in service mix cost.
19 Cohort PMPM Costs: by Service Mix PMPM costs by service mix for the cohort over the period immediately prior to enrollment through the end of the analysis period (latest data available) 19
20 20 Highlights of Health Home Rate Restructuring Effective May 1, 2018 Streamlined the current adult rates to create a more efficient documentation standard and align each rate with a corresponding risk and acuity with functional assessment of need Simplification and reduction in number of codes. Restructured the Adult rates into 3 as follows: High Risk High Need Care Management- includes all HARP and HIV/SNP members who do not meet HH + criteria Health Home Plus - serves the highest risk members meeting high risk and additional clinical criteria issued by OMH and the AIDS Institute Health Home Care Management - includes any enrolled member who does not meet the criteria for HH+ or High Risk/Need Care Management
21 21 Health Home Quality, Innovation and Performance Initiatives Plan incentives to Enroll High Risk Members in Health Homes April 1, 2018 Penalty for failure to enroll HARP and other high risk/cost members (adults and children) Up to 50% of penalty may be passed down to the Health Home No Penalty if both parties working collaboratively with best effort documented Rates of penalty will be tiered based on plan relative performance Health Home MCO Workgroup to build enrollment targets and penalty structure Health Home Healthy Rewards Program April 1, 2018 Plan administered rewards program for Health Home members that participate in wellness and preventative care (e.g., annual physicals, smoking cessation, continuous enrollment in Health Homes with care plan progress)
22 22 Health Home Quality, Innovation and Performance Initiatives Health Home Quality Incentive Pool October 1, 2018 Quality Incentive Pool - penalties on underperforming Health Homes and care management agencies and rewards for higher performers Performance measures - CMS and other measures may also include select process measures (e.g., maintaining caseloads that don t exceed 10% of recommended levels) Pool Funding - HH rates reduced and redistributed based on pre-established quality goals. Pool Structure - Health Home/MCO Quality subcommittee develops process for establishing penalties and distributing rewards to high performers
23 May Health Home Quality, Innovation and Performance Initiatives Reforming Outreach through Plans Flexibility October 1, 2018 Outreach Rate reduce rate and redirect outreach to the Plan for reform Outreach Plan MCOs will submit a detailed Outreach Optimization Plan to locate and enroll high risk members in Health Home (e.g., outreach to shelters, hospitals, LDSS) Tracking - Plans will be required to document and track the use of outreach resources Outreach Models State will issue model outreach approaches that do not require prior approval Learning Collaborative - Full day Learning Collaborative in June 2018 to develop recommended Outreach Reform Proposals with Plans and Health Homes
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