Charting New Territory: Ombudsman Programs and Dual Demonstrations Gabriela Trujillo Williams, Administration for Community Living Francine Chuchanis, Direction Home Akron Canton Area Agency on Aging & Disabilities Teresa Teeple, Ohio Office of the State Long-Term Care Ombudsman
Putting the Pieces Together on the Road to Integrated Care: The Demonstration, the Ombudsman & ACL Gabriela s Presentation
MyCare Ohio Ombudsman Demonstration Teresa Teeple Ombudsman Systems Liaison/ MyCare Ohio Ombudsman Demonstration Coordinator aging.ohio.gov/services/ombudsman 3
The Office of the State Long-Term Care Ombudsman advocates for excellence in long-term services and supports wherever consumers live. 4
Structure of the Office State office 12 regional ombudsman programs Variety of structures (AAAs, stand alone, etc.) 6 involved in the demonstration SLTCO designation and certification of representatives of the Office Roughly 85 paid staff and 238 volunteers 5
Older Americans Act 6
Ohio State law enhancement 7
3-way contract 8
Goal: integrated care Seven geographic regions covering 29 counties, 112,153 beneficiaries* MCOs: Aetna, Buckeye, CareSource, Molina and UnitedHealth Care Beneficiaries must be dually eligible and 18 + (some exceptions) 9
Benefits Benefits include all those available through traditional Medicare and Medicaid programs, including LTSS and behavioral health Plans may elect to include additional value-added benefits in health care packages 10
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Benefits also include One point of contact for care Care management support 24/7 Interdisciplinary team Waiver services coordinator One ID card Focus on prevention and wellness Nurse advice line 14
AAA role in MyCare Ohio Only state demo where AAA involvement is mandated Plan required to request LOC determinations from AAA for members needing waiver services Plan is required to contract with AAAs to perform Waiver Service Coordination (WSC) for members 60+ (alternative must be offered) 15
Who provides the services? 16
Our philosophy of involvement Managed care is here to stay Relationship building Learn new systems during demo Influence and inform systems change Program is positioned well for opportunity Many of these beneficiaries are already our clients You are an ombudsman first (training, ethics, certification/designation, etc.) 17
What s the same and what s different? Population: community well, waiver, nursing home Consumer complaints and inquiries 1,559 complaints (1,276 from consumer or family/friend) 985 inquiries New: out of network providers, opt in/out issues Hearing more about DME, in home services, care management, transportation (Some) new partners, (some) new conversations 18
Data overview 160 Ombudsman MyCare Ohio Complaints and Inquiries, by quarter 140 120 100 80 60 40 20 0 Year 1- Q1 Year 1- Q2 Year 1- Q3 Year 1- Q4 Year 2- Q1 Year 2- Q2 Year 2- Q3 Year 2- Q4 Year 3- Q1 Year 3- Q2 Year 3- Q3 Year 3- Q4 Year 4- Q1 Complaints Inquiries 19
What s the same and what s different? Systems issues Person-centered care/planning and care management processes, durable medical equipment, provider reimbursement, etc. Opportunities to communicate Quarterly plan meetings Member advisory committee meetings Ohio Department of Medicaid meetings 20
Program lessons learned Adapting and evolving at regional level Importance of face to face visitation ( MyCare isn t phone care ) Training/technical assistance for regional programs Marketing/communication strategies Communication is paramount 21
Charting New Territory The Ombudsman Experience Francine Chuchanis, Director of Entitlement Rights Certified Ombudsman Program Director
Traveling a New Boulevard Initiation into variety of home care services & delivery mechanisms Necessity to advocate with multiple providers Medicaid rules in community settings Utilization of a 3-Way Contract No one size fits all model
Maneuvering with Caution Developing relationships with My Care Plans and providers Identifying one point of contact with plans Struggle with leadership versus care management contact Securing role at Member Advisory Councils Partnering with Ohio Department of Medicaid
Navigation Challenges Multiple My Care Plans Diverse leadership styles Variations in timeliness of communications Differences in structures of member Advisory Councils Differences in regional access to providers Diversity of care management models Different appeal processes and rules
Divergent Routes Role of AAAs carved in for waiver service coordination only Full delegation of care management in AAAs by some plans, not others Some Ombudsman Programs in AAAs, others not Access to information by Ombudsman varies LTCOP firewalls instituted in AAAs
Early Bumps in the Road Enrollment Confusion about Opt-In/Opt-Out rights Timely assessments Transportation Access to primary care physicians Confusion about transition requirements Problems with provider billing and payments
Plotting a Smoother Pathway Ombudsman identify systemic issues Complaints against plans & Ohio Department of Medicaid (ODM) opened by Ombudsman Office of State Ombudsman reports complaint data to CMS ODM meets with plan stake holders Adjustments initiated to correct systemic issues & collect relevant data
Current Roadblocks Limited access to providers Untimely delivery of durable medical equipment Provider payment issues Timing of service start ups with transitions between care settings Care plans not person centered Shortage of home care attendants Absence of real exposure in nursing homes
Finding Detours Quarterly meetings with plan leadership Direct contact between Care Managers and Ombudsman Interaction with members at Advisory Council meetings Role of Ombudsman integrated into My Care Ohio
A Route to Success: Lessons Learned Early education of providers and consumers important DME process needs to be leaned Provider payment mechanisms need to be streamlined and timely Enrollments & authorizations during transitions must be well-timed Training needed on person centered care Rate adjustments for home care attendants essential
Mapping the Future Demonstration ends 2019 Many issues identified and being addressed MLTSS to go statewide in 2018? Move to One Waiver Some efforts to delay this in Ohio legislature Managed Care Plans submit intent to participate this Summer, ODM to choose by Fall Role of AAAs carved in for waiver service coordination Role of Ombudsman expanded
And FINALLY Ombudsman can help direct the future of managed long term care to the satisfaction of all