LONG TERM CARE INTEGRATION
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1 LONG TERM CARE INTEGRATION Kristen D Smith, MPH Aging Program Administrator Aging & Independence Services County of San Diego Health and Human Services 1/11/2017 1
2 COUNTY OF SAN DIEGO Building Better Health Living Safely Thriving Health and Human Services Agency (HHSA) Aging & Independence Services (AIS) 2
3 AIS FUNDING SOURCES Local Federal Grants State 30+ Programs Other Payers 3
4 AGING & INDEPENDENCE SERVICES In-Home Supportive Services APS Caregiver Respite PA/PG/PC Fall Prevention Ombudsman Diabetes Prevention Alzheimer s Diabetes Self-Management Chronic Disease Self-Management Intergenerational Case Management: MSSP, Linkages SOAR, SD-VISA Live Well Care Connection Volunteerism Outreach & Education AIS Call Center 40 Years of Experience 4
5 HEALTH PROMOTION PROGRAMS Tai Chi: Moving for Better Balance Feeling Fit Club Chronic Disease Self-Management Diabetes Prevention Program Diabetes Self-Management 5
6 TRANSFORMING CARE ACROSS THE CONTINUUM HEALTHY SAN DIEGO CCTP COORDINATED CARE INITIATIVE ADRC LONG TERM CARE INTEGRATION PROJECT LIVE WELL CARE CONNECTIONS WHOLE PERSON WELLNESS ALZHEIMER S PROJECT Age Friendly & Dementia Friendly ACL Grant 6
7 WHAT IS AN AGING & DISABILITY RESOURCE CONNECTION (ADRC)? Trusted source of comprehensive objective information, counseling, and assistance that empowers consumers regardless of the source of financing (Medi-Cal, Medicare, private insurance, federal or state-funded programs or consumer fees) to meet their personal goals for health and independence. ADRC s core services: Information/Assistance & Referral Options Counseling Short Term Service/Case Management Care Transitions
8 SAN DIEGO CARE TRANSITIONS PARTNERSHIP COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP) January 2013 present 4 health systems and AIS Over 56,000 patients Coleman Care Transitions Intervention Care Enhancement 1/11/2017 8
9 PERFORMANCE AIS is a current CMS contractor to deliver care transitions services for hospitalized high-risk Medicare fee-for-service beneficiaries CMS Evaluation of AIS care transition program 74.8 % reduction in readmissions N = 49,905 served from Feb 2013-Jul % 30% 20% 10% 30-Day Readmission Rate 39.8% % 0% 2012 (Baseline) 2/13-7/16 (CCTP Completers) 9
10 COORDINATED CARE INITIATIVE / CAL MEDICONNECT Medi-Cal Managed Long-Term Services & Supports (LTSS) Cal MediConnect (duals demonstration) MANDATORY VOLUNTARY Enrollment of approximately 64,000 Medi-Cal recipients into a Medi-Cal managed care health plan for: Medi-Cal benefits, including Long Term Services & Supports (LTSS) Medicare wrap-around benefits Enrollment of 14,000 of the approximate 57,000 dual eligibles in San Diego County into the three-year demonstration program for coordinated Medicare & Medi-Cal benefits through a single delivery system. In-Home Supportive Services (IHSS) - 27,000+ Multipurpose Senior Services Program (MSSP) 550
11 SAN DIEGO COORDINATED CARE INITIATIVE 550 MSSP Clients 27,000 IHSS Clients 15,000 CMC Members Successful integration: Care Coordination Unit Program Implementation Guide Informal case consults and ICT s Data sharing Infrastructure for ongoing communication (CCI Advisory Committee, AIS-CCI Health Plans Committee) 1/11/
12 SAN DIEGO COUNTY COORDINATED CARE INITIATIVE Successful integration: Infrastructure for ongoing communication (CCI Advisory Committee, AIS-CCI Health Plans Committee) Program Implementation Guide Care Coordination Unit Informal case consults and ICT s Data sharing 12
13 LIVE WELL CARE CONNECTIONS Assess: Physical health, ADL s, IADL s Fall risk, Medications Nutrition Risk Mental/Cognitive/Social Home Environment Life planning, financial Caregiver needs Client Priorities & Goals Long Term Services and Supports (LTSS): Meals, transport, chores, grab bars, home care, respite health promotion Care Plan: Coordination w/medical Informal & self-management Gov t & Community Purchased Services 13
14 LWCC PARTNERS Live Well Care Connections Funder/Partner: Palomar Partners in Care Foundation (for Blue Shield of California) COMING SOON Alzheimer s ACL Grant More TBD 14
15 GOAL, SCORING & BENEFITS OF ACCREDITATION 3 YEAR CASE MANAGEMENT LTSS ACCREDITATION Scoring thresholds associated with each status are shown in the table: ACCREDITATION STATUS STANDARDS SCORE Accredited- 3 years Accredited- 2 years Denied Below 70 NCQA Case Management LTSS Final Standards 8 Standards 37 Elements 170 Factors 15
16 THE ALZHEIMER'S PROJECT Care & Safety Cure LEGISLATION & FUNDING Clinical Education & Awareness
17 ACL ALZHEIMER S DISEASE INITIATIVE: SPECIALIZED SUPPORTIVE SERVICES FIRST - $1million over 3 years: First, Identify & Refer Serve Assessment Behavioral Symptom Management Respite and other LTSS Track 17
18 1/11/
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