Community Health Care Association of New York State Conference and Clinical Forum October 18, 2011 1
Section 2703 of the Patient Protection and Affordable Care Act (ACA) provides states, under the state plan option or through a waiver, the authority to implement health homes. opportunity to address and receive additional federal support for the enhanced integration and coordination of primary, acute, behavioral health (mental health and substance use), and longterm services and supports for persons with chronic illness. provides 90 percent FMAP rate for health home services for the first eight fiscal quarters that a health home state plan amendment is in effect; multiple SPAs permitted. 2
At least two chronic conditions, one chronic condition and at risk for another, or one serious and persistent mental health condition. Chronic conditions include but are not limited to: mental health condition substance abuse disorder asthma diabetes heart disease, being overweight (BMI over 25) HIV/AIDS Hypertension 3
Enrollees in the behavioral health category will be identified through claims and encounter data. They often have co-morbid chronic, medical conditions and unmet social needs such as a lack of permanent housing Enrollees in the chronic medical condition category will be identified through claims and encounter data as having two or three chronic medical conditions including HIV/AIDS. The State will use a combination of clinical risk groups (CRG), an algorithm that predicts hospitalizations, and behavioral health indicators to select Medicaid enrollees for health homes. 4
Total Complex N=976,356 $2,338 PMPM 32% Dual 51% MMC $25.9 Billion 5
Medical Home for Patients with Risk Score 50 Based on Prior 2-Years of Ambulatory Use Source: NYU Wagner School, NYS OHIP, 2009. 6
Must be enrolled (or be eligible for enrollment) in the NYS Medicaid program and agree to comply with all Medicaid program requirements. Can either directly provide, or subcontract for the provision of, health home services. Responsible for all health home program requirements, including services performed by the subcontractor. Care coordination and integration of heath care services will be provided to all health home enrollees by an interdisciplinary team of providers, where each individual s care is under the direction of a dedicated care manager who is accountable for assuring access to medical and behavioral health care services and community social supports as defined in the enrollee care management plan. Must meet standards for delivery of six core health home services as described in following slides. Must provide written documentation that clearly demonstrates how the requirements are being met. 7
Health home providers will be required to provide the following health home services in accordance with federal and State requirements: Comprehensive care management An individualized patient centered care plan based on a comprehensive health risk assessment must meet physical, mental health, chemical dependency and social service needs. Care coordination and health promotion One care manager will ensure that the care plan is followed by coordinating and arranging for the provision of services, supporting adherence to treatment recommendations, and monitoring and evaluating the enrollee s needs. The health home provider will promote evidence based wellness and prevention by linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help recovery resources, and other services based on need and patient preference. Comprehensive transitional care Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up care. Patient and family support Individualized care plan must be shared with patient enrollee and family members or other caregivers. Patient and family preferences are considered. 8
Health home providers will be required to provide the following health home services in accordance with federal and State requirements: Referral to community and social support services Provider will identify and coordinate community and social supports Use of health information technology (HIT) when feasible Health home providers will be encouraged to utilize RHIOs or a qualified entity to access patient data and to develop partnerships that maximize the use of HIT across providers. Health home provider applicants must submit a plan with their application for achieving compliance with the final health home HIT requirements within 18 months of program implementation 9
NY will be using quality measures that fall into the following categories: Measures collected from claims and encounters Measures currently collected by managed care plans Measures per NQF and/or meaningful use measures New measures that meet federal reporting requirements 10
NY will use designated providers for the Health Home Program Designated providers can be: Managed Care Plans Hospitals Medical, mental and chemical dependency treatment clinics Federally Qualified Health Centers (FQHCs) Targeted Case Management (TCM) programs Primary care practitioner practices Patient Centered Medical Homes (PCMHs) Any other Medicaid enrolled entity that meets NY s health home requirements Considering adding other long term care providers 11
NY is seeking applicants that : have strong medical, behavioral, and social service community providers connections use multi-disciplinary teams of medical, behavioral, TCM, and social services providers that can assure appropriate and timely access to services. Each patient enrollee will be assigned a single care manager who is responsible for managing and coordinating their care. There will be only one care plan for each patient enrollee. All members of the health home team will report back to the care manager on patient status, treatment options, actions taken, and outcomes. Health homes will be responsible for reducing or eliminating costs associated with avoidable inpatient and emergency room visits and improving patient outcomes. 12
976,000+ high cost/high need Medicaid enrollees (1) Chronic conditions at risk for a 2 nd nd chronic condition (2) Chronic conditions Yes Patient Meets Health Home Criteria Assigned a Health Home Patient Assessment* (1) Serious & Persistent Mental Health Condition *Medically and Behaviorally Complex Non-Compliant with Treatment Health Literacy Issues ADL Status Inability to Navigate Health Care System Social Barriers to Care Homelessness Temporary Housing Lack of Family or Support System Food, Income Need assistance applying for Entitlement Programs Level I Health Home Services Moderate Need Level II Health Home Services Multiple Complex Needs Level III Health Home Services Intensive Complex Needs Periodic Reassessment * for continuation of Health Home Services Health Home Services Not Required Primary Care Practitioner Manages 13
Contract with HHs Medicaid Agency MCO/ BHO MCO/ BHO HH HH PCMH CMHC Other MCO plus provider = HH MCO/BHO/ACO is HH 14
The State will use a combination of the following to assign Medicaid enrollees to Health Homes: clinical risk groups (CRG), an algorithm that predicts hospitalizations, and behavioral health indicators Medicaid enrollees will be assigned to a health home, to the extent possible, based on existing relationships with ambulatory, medical and behavioral health care providers or health care system relationships, geography, and/or qualifying condition. Initial assignments will be for members who qualify for Health Home services but currently do not have a meaningful primary care or case management connection. Patients will not be moved from their current TCM/COBRA, CIDP, MATS 15
The State will also include any supportive housing services an individual may have in keeping those connections in health home assignments. Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment. The State will provide health home providers a roster of assigned enrollees and current demographic service access information to facilitate outreach and engagement. With the exception of TCMs, where special arrangements may be made, Medicaid members enrolled with plans will be assigned into Health Homes by the plan utilizing loyalty and attribution data provided by the state. 16
165 LOIs received Many comprehensive well thought through networks Some concerns about specific network adequacy issues Some LOIs have more comprehensive networks than others Some overlapping regions and partners Some smaller less robust entities that should merge DOH is working with OMH, OASAS and NYCDOHMH to assess network adequacy and suggest additional network partners and any appropriate mergers 17
Phase I - 13 counties: Bronx, Kings (Brooklyn), Nassau, Monroe, Warren, Washington, Essex, Hamilton, Saratoga, Clinton, Franklin, St. Lawrence, Schenectady HH application due date for Phase I counties only is November 1, 2011. Implementation is scheduled for January 1, 2012 Phase II ** 14 Counties: Manhattan, Queens, Richmond (Staten Island), Suffolk, Westchester, Rockland, Orange, Putnam, Dutchess, Ulster, Sullivan, Erie, Albany, Rensselaer HH application due date for Phase II counties only is February 1, 2012. Implementation is tentatively scheduled for April 16, 2012. Phase III ** 35 Counties: Alleghany, Cattaraugus, Chautauqua, Niagara, Genesee, Orleans, Wyoming, Livingston, Ontario, Broome, Cortland, Cayuga, Chenango, Oswego, Jefferson, Madison, Steuben, Schuyler, Chemung, Yates, Seneca, Wayne, Tioga, Fulton, Oneida, Otsego and Onondaga, Montgomery, Columbia, Greene, Delaware, Schoharie, Lewis, Herkimer, Tompkins HH application due date for Phase III counties only is April 21, 2012. Implementation is tentatively scheduled for June 18, 2012. **Please note that Health Homes approved to provide Health Home services under Phase I will need to resubmit their application with updated information for Phase II and III if they plan to provide Health Home services to Medicaid enrollees in these counties. 18
Finalizing roles of responsibilities for managed care plans Targeted Care Management transition Network adequacy review and feedback Final CMS SPA roles (outreach and engagement; quality measures) Rate adequacy feedback (HIV upweights, etc.) 19
NYS Health Home Web site (links to many relevant materials): http://nyhealth.gov/health_care/medicaid/program/medicaid _health_homes/index.htm. Questions and/or comments regarding New York's implementation of health homes can be directed to hh2011@health.state.ny.us. 20