Long Term Care There s No Place Like Home. Presented by: Chad Corbett, M.P.A., HS-BCP October 31, 2012
About Mercy Care Plan (MCP) Long Term Care In 2007, Aetna acquired Schaller Anderson, a managed Medicaid company. Schaller Anderson was created in 1987 by founders who helped re-shape Arizona Medicaid, the nation's first statewide Medicaid program based on managed care principles. We manage: Services for more than 1.3 million members nationwide* $3.5 billion in health care expenses annually We utilize managed care strategies and tools through a variety of business models, including non-risk managed care organizations, enhanced PCCM and ASO services. Our keys to success: Partnership, clinical integration and technology. More than two decades of Medicaid experience, managing an array of Medicaid populations, including TANF, SCHIP, ABD (including physically and developmentally disabled), LTC and Children with Special Health Care Needs (including foster care children). * 1 million members and 300,000 members in targeted managed care programs 2
Managed care for duals and non-duals who are long-term care eligible is a win-win! An AARP study shows 87% of people age 50 and older or those who are physically disabled want to receive services in their own home. Win for long-term care (LTC) Medicaid recipients who prefer a plan that offers them choice of where they receive services. 3
Who needs long-term care services? 10 million Americans, 5% of the population, needed LTC services for daily-living activities in 2000. 25 Baby Boomers With 76 million baby boomers now approaching retirement age, the number of Americans who will need LTC services is expected to double by 2040 to 21 million members. Millions 20 15 10 5 0 2000 2040 4
What is Long Term Care? Long-Term Care (LTC) refers to a broad range of services that support people who have limited ability to care for themselves due to physical, cognitive, or chronic health conditions. These conditions are expected to continue for an extended period of time (verses a short time such as after surgery) Care needs arise because: Underlying health conditions common in older adults. A condition or injury acquired during lifetime A condition present at birth. 5
What is Long Term Care? A person needing Long-Term Care will require assistance with: Activities of Daily Living (ADL s) such as bathing, dressing, eating, transferring, walking and/or Instrumental Activities of Daily Living (IADL S) such as meal preparation, money management, housecleaning, grocery shopping, transportation. 6
Individuals needing assistance get their care in: Institutional or nursing facility placement A community placement such as a group home or assisted living. In their own home either living alone, living with family members 7
MANAGED LONG TERM CARE How Does It Work in Arizona? 8
Getting Old in Arizona In most other States, these are choices: Assisted Living (Private Pay) Skilled Nursing Facility (Medicaid) Small HCBS Waiver (Usually less than 2,000 individuals) In Arizona, there are many more choices: SNF (less than 30% statewide) Assisted Living Centers (Medicaid paid) Assisted Living Home (Medicaid paid) Adult Foster Care (Medicaid paid) Attendant Care in your Own Home (Medicaid paid) Attendant Care Family Paid (Medicaid paid) 9
Placement Statistics Placement Statewide Nursing Facility 30% HCBS: 70% Home 78% ARS 20% Other 2% Mercy Care Plan Nursing Facility: 24% HCBS: 76% Home 82% ARS 15% Other 3% 10
Current Long-Term Care Population One-third: Physically disabled, younger than 65 years old Two-thirds: elderly, older than 65 years old 11
Mandatory Program, Under Statewide 1115 Waiver To be eligible, members must be certified by the State as being at risk for nursing home placement Over 25,000 Elderly/Physically Disabled (EPD) members Statewide 12
ALTCS Principles: Prepaid, capitated approach through public/private partnerships. Integrate all long term care services by bundling acute care, long term care, case management, and behavioral health services. Pre-admission screening process to identify those at risk for institutionalization. Eligibility completed by the State Full continuum of services to ensure members are placed in least restrictive, most cost-effective care. Primary care physicians/case managers serve as gatekeepers to coordinate care. 13
What is Mercy Care s Long Term Care Model? Home & Community-Based Services (HCBS): Consumer-directed care Full array of home & community-based support Adult Day Care Support services Home modifications Assistive equipment Durable medical equipment (DME) Member Centered Approach Non-Medicaid Community Supports Residential Care Facilities: Adult Foster Care Assisted Living Institutional Care (NF) Long-term Specialty Care/Sub-acute Medical/Acute Services : Cost sharing for duals 14
What is Mercy Care Plan s Integrated Long Term Care Model? Member-centered approach that enables members to tailor services according to their individual needs and preferences Care coordination enables members to reside in the least restrictive setting possible, while supporting maximum independence Service-integration model for elderly and physically-disabled persons that includes acute care, behavioral health, institutional care and a full continuum of HCBS Risk-based, fully or partially capitated financial structure that provides incentives for the most cost-effective placement of individuals 15
Mercy Care Plan s Integrated Long Term Care Model Mercy Care Plan s Integrated Long-Term Care Model includes: A full array of HCBS services, including consumer-directed care, assisted living, personal care and family caregivers, home modifications and nursing Institutional care, including contract negotiation, level-of-care determinations, unique unit development to serve specialized populations and advocacy to support resident transfer from nursing facilities to HCBS Acute care, including all covered medical services for non-duals and Medicare cost sharing and wrap-around benefits for duals 16
The Assessment Form 12 pages Long (Average) 1-2 hours to complete Rich clinical information (ex: fall risk assessment, depression screen) Functional status and fall risk assessment/skin risk Current medications Depression Screening Designed to support case management referrals Patient contact Information Active/inactive/chronic medical diagnoses that impact the patient s care Includes considerations for PCP in managing member Incorporates HEDIS measures and 5 Star Rating components 17
Tools/Processes Assessment Skin & Fall Evaluation Service Plan PCP Initiative Checklist IDT Staffing & Behavioral Health Consultations Hospital Admit Report MCA Post Discharge Program Care Management Agreements Diabetes, Flu, & Advance Directives Assessment Process End to End Case Managers complete these tools at each assessment: Acuity Tool Attendant Care Worksheet (HCBS only) Contingency Plan (HCBS only) Member & Provider Handbook Review (new members and annually) 18
Post Assessment: Data Entry Case Managers are required to enter the following into Case Trakker (case management software system) Assessment Assessment Note Medications Diagnosis Placement Data Behavioral Health Data Advance Directives PCP Initiative Flu Data Diabetes Data 19
Differentiators: Mercy Care Plan has deep experience in managing high risk members MCP Case Managers assess members in multiple settings including home, nursing home and skilled nursing facilities In business since 1985 Experience with Medicare Advantage, Special Needs Plans and Medicaid Program Attributes Care Consideration Letters Home Physician Program Activate Program 20
Care Consideration Letters: Tracking Tracking Number: Number: 12345678 12345678 Date: Date: 7/8/2009 7/8/2009 Care Care Consideration: Consideration: Statins Statins - Avoid Avoid Use Use With With Elevated Elevated CPK CPK or or Transaminases Transaminases - #161C #161C Your Your patient patient has has claims claims evidence evidence for for statins, statins, and and for for lab lab data data indicating indicating elevated elevated liver liver transaminases transaminases greater greater than than 3 times times upper upper limit limit of of normal normal and/or and/or an an elevated elevated creatine creatine kinase. kinase. Statins Statins should should be be avoided avoided in in the the presence presence of of liver liver dysfunction dysfunction and/or and/or myopathy. myopathy. If If your your patient patient fits fits this this clinical clinical profile, profile, and and if if not not already already done, done, consider consider reassessment reassessment of of the the risks/benefits risks/benefits of of continuing continuing statins. statins. Clinical Issue Lexi-Comp Lexi-Comp Drug Drug Information Information Handbook Handbook - 17th 17th Edition Edition (2008-2009) (2008-2009) Physicians' Physicians' Desk Desk Reference Reference 2009 2009 Journal Journal of of the the American American College College of of Cardiology; Cardiology; ACC/AHA/NHLBI ACC/AHA/NHLBI Clinical Clinical Advisory Advisory on on the the Use Use and and Safety Safety of of Statins; Statins; 2002;40:567-572 2002;40:567-572 Code Description Occurs Starting Ending Member Data 51079045601 SIMVASTATIN 40 MG TABLET 15 6/21/2006 7/4/2009 2157-6 Creatine kinase 1 7/1/2009 7/1/2009 6524300651 SIMVASTATIN 20 MG TABLET 12 1/14/2004 4/24/2006 Physician Survey 21
Care Consideration Letters Key Features Real-time delivery near point of contact Includes clinical basis for observations and recommendation Designed to be read in less than a minute Concise, containing essential information Limited to three or fewer diagnostic opportunities Why Our Approach Works Clinical Analytics Robust set of algorithms Rich set of data sources employed by analytic algorithms Highly accurate findings; low false positives Designed to be read in less than a minute Concise, containing essential information Limited to three or fewer diagnostic opportunities Real-time delivery or near the point of contact Built on just-in-time industrial management techniques 22
Role of the Case Manager with Integrated Models 23
Care Management Integrating Services Responsible for managing entire member: Acute, Long Term Care, Behavioral Health Medical: Hospital Discharge, PCP Visits, DME, Pharmacy Functional: In-home Care, Assisted Living, SNF Behavioral Health: Full array of BH services carved in 24
Care Management Integrating Care Member must always be present at assessment. Families, Rep, Informal Supports always invited to participate. SNF- Care Conference in SNF ALF Conference with homeowner or staff Caregivers/Agency consulted Care Plans going to PCP BH Consult Letter to Prescriber 25
Training New Hire Training 3 weeks of Shadowing 56 hrs. of Training Assessing Needs & Coordinating Care Ongoing Training Medical Conditions Community Organizations 26
Age Breakdown by Placement (Sept. 2012) Age Home & Community ALF SNF Acute Care No LTC Svcs. Total by Age 0-19 166 7 9 92 277 20-29 233 31 15 15 297 30-39 244 34 41 5 328 40-49 430 112 110 13 671 50-59 762 205 256 8 1,253 60-69 937 277 399 6 1,642 70-79 1,127 321 485 12 1,963 80-89 1,033 480 656 12 2,205 90-99 309 240 267 3 826 100-109 14 6 3 0 39 27
Role of Case Manager Per Contract: Case load weights: SNF CM ratio 1:120 Visit every 180 days As needed in care planning to resolve issues New Admission ALF CM ratio 1:60 Visit every 90 days As needed in care planning to resolve issues New admission HCBS CM ratio 1:48 Visit every 90 days Discharges from SNF or ALF As need in care planning to resolve issues. 28
Case Manager Responsibilities: Case Managers assigned on day 1 of enrollment. Case Managers contact member within 5 business days to schedule new appointment. Case Managers visit and complete Assessment with new member within 12 business days of enrollment. Case Manager is required to Initiate services within 30 calendar days of enrollment. 29
30 MCP Health Outcomes & Quality Measures
Rebalancing Institutional and HCBS Services A recent AARP study shows the majority of people age 50 and older and those with disabilities want to age in place and prefer to live in their own home. States are making progress toward rebalancing institutional services to HCBS: Note: HCBS includes home health, personal care services and home and communitybased service waivers. Source: KCMU and Urban Institute analysis of HCFA/CMS- 64 data. 31
Rebalancing Institutional and HCBS Services MCP Medicaid s Integrated Long-Term Care Model has been very successful in Arizona. We have been a proud partner with the state since 1989 32
Dual Eligibles January 1, 2006 Mercy Care Plan passively enrolled over 14,000 dual eligible members into Medicare Advantage (MA) Special Needs Plan (SNP) Mercy Care Plan s Long Term Program has: 79.5% dual eligible members 50% are with MCP s SNP (MCA) Dual members not enrolled with MCA are either with another MA Plan or the Traditional FFS Medicare 33
ALTCS Outcomes Annual growth of capitation paid to plans has consistently remained lower than trend for LTC Services. Reasons: Percentage of members residing in alternative residential settings has doubled Proportion of members remaining in their own home continues to increase Percentage of members in Nursing Homes has consistently decreased According to an external study, ALTCS saved approximately 16% per year over what would have been spent had the members remained in a FFS environment 34
What Members are Saying About ALTCS 93% of members were satisfied with their case manager 91% of members were satisfied with their doctor 95% of members were satisfied with their home and community based caregiver 93% of members were satisfied with their nursing facility caregiver 35
Summary Mercy Care Plan s Integrated LTC Model provides many valuable opportunities, including: Improved health outcomes Improved access to care Cost savings Budget predictability Consumer satisfaction Remember There s No Place Like Home... 36
We want to hear from you Contact Chad Corbett, Vice President of Mercy Care Plan Long Term Care, at 602 453-6065 or CorbettC2@AETNA.com 37