Best Practices for Integrated Care Teams Cal MediConnect Providers Summit January 21, 2015 Moderator: Alexandra Kruse, Senior Program Officer, CHCS www.chcs.org
Interdisciplinary Care Teams Providers have a key role to play in the Interdisciplinary Care Team (ICT) for Cal MediConnect enrollees Primary interdisciplinary care team functions^ Assessing the enrollee s health status and needs, on an ongoing basis Care planning Facilitating and coordinating the delivery of services Facilitating transitions between institutions and the community Facilitating enrollee engagement in their care plan Will discuss health plan and provider experience with interdisciplinary care teams, as well as more broadly, other integrated care team arrangements ^ Cal MediConnect Care Coordination Fact Sheet available as part of the Physician s Tooklit found at http://www.calduals.org/physician-toolkit/ 8
CareMore Model of Care George Fields, D.O. Chief Medical Officer CareMore Essentials George.Fields@caremore.com Phone: 866-646-3553
10
Cal MediConnect Providers Summit January 21, 2015
INTRODUCTION 40 years serving the underserved communities in So. Cal Largest independent Federally Qualified Health Center (FQHC) 43 sites in Los Angeles and Orange Counties Serves 150,000 families with 930,000 patient visits per year Provides healthcare from birth to senior years Contracts for Medi-Cal, Medicare, Commercial members Designation as Primary Care Medical Home (PCMH) 4 Star Rating Malcolm Baldridge Award 12
INTRODUCTION (CONTINUED) Provides healthcare from birth to senior years Primary & Specialty Medical Care Dental Clinics Senior Long-Term care services and case management Program of All Inclusive Care for the Elderly (PACE) Disease Management Health Education Youth Services HIV/AIDS Substance Abuse treatment AltaMed very active in enrolling community into the ACA Enrolled most number of people into the Exchange & Expansion Honored to serve the Cal MediConnect members 13
CAL MEDICONNECT (CMC) Preparing to serve dually eligible beneficiaries since 2012 Began receiving membership June 2014 in Los Angeles High priority to integrate CMC members into our system Making certain member accurately tied to prior provider Continuity of Care is administered Emphasis on initial claims & health risk assessment (HRA) data to prioritize outreach Individual Care Plans being created on all CMC members Initial Health Assessments being scheduled Interdisciplinary Care Teams scheduled with member/caregiver Care Coordination with DME, MSSP, SNF, Primary/Specialty Enterprise-wide meetings to monitor progress 14
COORDINATED CARE TEAM PATIENT CENTERED CARE 15
COORDINATED CARE TEAM 16
COORDINATED CARE TEAM INTERDISCIPLINARY CARE TEAM SELF MANAGEMENT PLANNING CARE PLANNING ADDRESS REFERRAL ISSUES (MEMBER/PROVIDER) PROVIDE EDUCATIONAL MATERIALS HELP MEMBERS NAVIGATE HEALTHCARE SYSTEM ONGOING FOLLOW UP WITH MEMBER BASED ON RISK LEVEL AND MEMBER NEEDS LIAISON BETWEEN MEMBER AND PROVIDER DETERMINE HOME BASED CARE NEEDS ASSIST WITH APPOINTMENT MEDICATION MANAGEMENT & EDUCATION ASSIST WITH NEEDS OF THE OLDER ADULT PROVIDE LINKAGE TO OTHER PROGRAM (DSM) LINKAGE BETWEEN HOSPITAL & OUTPATIENT PROVIDER TRANSITION CARE PLANNING ASSIST WITH APPOINTMENT 17
SUCCESSES TO-DATE Created Coordinated Care Team to support the Cal MediConnect effort Ability to use historical claims, pharmacy, TAR s and Continuity of Care data to start creating care plans even before HRA s come in (measuring heavy ER usage, inpatient stays, high risk medications, etc.) In the absence of HRA s and historical claims data, using risk profile scores from the health plans as a means to stratify members and prioritize outreach efforts and resources Using analytics and creating dashboard to measure # of appointments being made, translation of appointments into IHA s, enforcing and measuring Model of Care (MOC) requirements (HRA, ICP, ICT) 18
SUCCESSES (CONTINUED) Using analytics to create a list of non-contracted providers with whom Letter of Agreement (LOA s) have to be established because of historical utilization and COC requirements Proactive systems setup & automation allowed AltaMed to divide the CMC population by region, by risk level (initial stratification), monitor HRA status, measure MOC statistics, etc. Capitation payments to PCPs for both Medi-Cal and Medicare payments is simpler 19
OPPORTUNITIES TO IMPROVE Accurate member contact information Health Risk Assessments (HRA) for all members Standardizing HRA for all health plans Claims paid amount would further assist in stratifying members Prior member-provider relationship sometimes not considered Retention of members 20
BEST PRACTICES Early planning and training modules for health care changes Hiring staff competent in key LTSS programs such as IHSS, CBAS, MSSP, LTC and hiring Social Workers Strong Data Analytics to stratify, prioritize, monitor program Ensure Behavioral Health Vendor and PCP in ICT Ensure LTSS provider/caregiver in ICT Development of Coordinated Care Model to meet the needs of vulnerable population Dedicated SNFist and narrow network of quality SNFs 21
San Diego Experience Joseph Garcia Chief Operating Officer Community Health Group 22
Integrated Care Teams Best Practices Joseph Garcia - Chief Operating Officer Community Health Group January 21, 2015
Questions and Discussion 24