Accountable Care Collaborative: Medicare-Medicaid Program (ACC:MMP) - - PowerPoint PPT Presentation

Colorado Department of Health Care Policy and Financing

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Accountable Care Collaborative:

Medicare-Medicaid Program (ACC:MMP)

Making Medicare and Medicaid work better together for our clients

Colorado Department of Health Care Policy and Financing

Improving health care access

and outcomes for the people we serve while demonstrating sound stewardship of financial resources

Department’s Mission:

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Colorado Department of Health Care Policy and Financing

• 1. Introduction to ACC: Medicare-Medicaid Program
• 2. Service Coordination Plan (SCP) Introduction
• 3. Coordinating with Other Providers

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What we will cover today

Colorado Department of Health Care Policy and Financing

• 1. Introduction to ACC: Medicare-Medicaid Program
• 2. Service Coordination Plan (SCP) Introduction
• 3. Coordinating with Other Providers

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What we will cover today

Colorado Department of Health Care Policy and Financing

• 10 million people nationwide rely on Medicare

and Medicaid

• Fragmented fee-for-service (FFS) delivery system
• Affordable Care Act authorization of state-led

demonstration programs to integrate care

• Colorado is one of 15 participating states
• 32,000 eligible clients

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Program Background

Colorado Department of Health Care Policy and Financing

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Colorado’s Medicare-Medicaid Enrollees

Top Five Mental Health Diagnoses for MMEs

Depressive Disorder NEC Anxiety State NOS Tobacco Use Disorder Other Alteration of Consciousness Schizoaffective-Unspec Percent of MMEs with Mental Health Diagnosis

38%

Colorado Department of Health Care Policy and Financing

• Improve MME health outcomes
• Decrease unnecessary and duplicative

services

• Promote person-centered planning
• Improve client experience through enhanced

coordination and quality of care

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ACC: Medicare-Medicaid Program Goals

Colorado Department of Health Care Policy and Financing

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Colorado Department of Health Care Policy and Financing

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ACC Components

Primary Care Medical Providers (PCMPs) Statewide Data and Analytics Contractor (SDAC) Regional Care Collaborative Organizations (RCCOs)

Colorado Department of Health Care Policy and Financing

• ACC allows RCCOs to delegate care

coordination to PCMPs and other appropriate entities

• Through delegation, PCMP completes SCP
• RCCO still responsible for ensuring SCP completion

and timely updates when delegated to PCMP

• Provider responsible for coordinating care

with client’s other providers and care coordinators

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Delegated Care Coordination

Colorado Department of Health Care Policy and Financing

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Traditional, unmanaged Fee-for- Service model Regional, outcome- focused, client/family- centered coordinated system of care

MMEs Now MMEs Later

ACC: Medicare-Medicaid Program Vision

Colorado Department of Health Care Policy and Financing

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Clients with LTSS receive: Case management - Single Entry Point (SEP) or Community Centered Boards (CCB)

Current System for MME’s

Often does not coordinate Primary Care, Acute, Sub-Acute, or Specialty Care

Acute care and hospital services Community

• Based

Services and Supports

• For clients not receiving Long-term Supports and Services (LTSS):

Often no one available to coordinate any of their services

Colorado Department of Health Care Policy and Financing

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Acute Care and Hospital services Community

• Based

Services and Supports

clients receiving LTSS: Existing Long-Term Care (LTC) “Service Plans” and

• ther assessments

largely inform the SCP

Service Coordination Plan

RCCO Coordinates both acute and community- based services for ALL enrolled clients

New System for MME’s

Coordination of Primary Care, Acute, Sub-Acute, and Specialty Care

Colorado Department of Health Care Policy and Financing

• 32,000 people to be enrolled over seven months
• Starting Sept. 1 and ending March 2015
• Clients separated into four categories to for

phased in enrollment:

• Community Well,
• Waiver High,
• Waiver Low, and
• Nursing Facility

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Program Enrollment

Colorado Department of Health Care Policy and Financing

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Program Enrollment: Categories Defined

Client Enrollment Classifications

Community Well

These clients are not nursing home certifiable and do not live in a nursing facility nor use waiver services on a consistent basis.

Waiver Low

These clients are not living in a nursing facility and utilizing waiver services on a consistent basis.

Waiver High

These clients are also not living in a nursing facility, but are very high utilizers of waiver

• services. These clients had to have an average PMPM of greater than $4,800 in waiver

services to be considered as part of this delivery system.

Nursing Facility Population

These clients reside in a nursing facility and have a nursing facility level of care. A client must have at least three consecutive months of nursing facility service to be considered as part of this population. (Clients with less than the three months of nursing facility service are considered “short term” and are captured in one of the other delivery systems.)

Colorado Department of Health Care Policy and Financing

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Monthly client Enrollment by Classification

7500 clients/month maximum

Sept Oct Nov Dec Jan Feb Mar

MMEs currently in ACC Community Well PCP in ACC Community Well PCP in ACC Community Well PCP not ACC No Enrollment Community Well PCP not ACC Waiver Low PCP not ACC Waiver Low PCP not ACC Waiver High PCP not ACC Nursing Facility residents for which CO Medicaid is primary payer (stay >90 days) Remainder of Nursing Facility residents for which CO Medicaid is primary payer (stay >90 days)

Colorado Department of Health Care Policy and Financing

• 1. Introduction to the ACC: Medicare-Medicaid

Program

• 2. Service Coordination Plan Introduction
• 3. Coordinating with Other Providers

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What we will cover today

Colorado Department of Health Care Policy and Financing

Centers for Medicare and Medicaid Services (CMS) requires:

• “Plan of care” for each enrollee
• Colorado’s plan of care is Service Coordination Plan (SCP)
• Enrollees determined “high risk” to have SCP completed

within 90 days

• All other enrollees 120 days
• SCPs must be updated every six months or as needed to

ensure client is on track and achieving health care goals

• Process for Provider Communication and Collaboration to

complete SCP = Provider Protocols

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Care Coordination Requirements

Colorado Department of Health Care Policy and Financing

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What is the Service Coordination Plan?

• Cornerstone of Program
• Helps identify gaps in care

and duplicative services

• Documents clients’ short-

and long-term goals

• Blueprint for meeting client

goals and improving health

• utcomes

Colorado Department of Health Care Policy and Financing

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• Promotes proactive, person-

centered, strength-based coordination of services and supports, including:

• Coordinating physical, behavioral

and social health needs for clients w/complex conditions

• System-level oversight and

support for people w/multiple case managers

• Promoting patient activation

Service Coordination Plan

Colorado Department of Health Care Policy and Financing

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• Single, comprehensive view of

all elements needed to coordinate client’s physical, behavioral and social health care services and supports

• Promotes communication and

coordination across delivery systems and among providers

• Completed w/client, capturing

their needs and wants

Service Coordination Plan

Colorado Department of Health Care Policy and Financing

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Service Coordination Plan Development

• SCP created through

collaborative effort between HCPF and RCCOs

• Incorporated feedback from

workgroup, RCCO care coordinators and advocates

• Tested by RCCO care

coordinators during development process

Colorado Department of Health Care Policy and Financing

• Shows you client’s wants, needs and

gaps in service

• Provide documentation that

resources were provided to client and their needs were met

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High Quality Service Coordination Plan

Colorado Department of Health Care Policy and Financing

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Colorado Department of Health Care Policy and Financing

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RCCO Determined High-Risk

• Duration of 1915(c) HCBS waiver

enrollment

• Functional, behavioral and/or

cognitive risks

• Change in existing Care Manager

relationship

• Observed risks for being

institutionalized

• Change in caregiver status/support
• Inpatient or emergency

department utilization

Eleven domains of prioritization:

• Presence and severity of

chronic conditions

• Residential housing status
• Poly-Pharmacy
• Gaps in care
• Stability of support system

Colorado Department of Health Care Policy and Financing

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Completion and Review Timeline

90 days

(3 months)

120 days

(4 months)

180 days

(6 months)

High-risk clients All other clients

SCP review for all clients

Colorado Department of Health Care Policy and Financing

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SCP – An Ongoing Process

• RCCO/Care Coordinator

conducts initial assessment

• Works w/client and PCMP to

maintain going forward

Review and revise every 6 months or as needed

Examples of as-needed situations:

• Significant change in the client’s needs
• Acute or critical incident
• Client, family or provider request
• Care transition
• Abuse or neglect

Colorado Department of Health Care Policy and Financing

• State-specific process measure
• Number of completed SCPs and client

names reported to Department monthly

• Monthly Department review of

completed SCPs

• Site audit reviews

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Required Reporting of Completed SCPs

Colorado Department of Health Care Policy and Financing

• 1. Introduction to the ACC: Medicare-Medicaid

Program

• 2. Service Coordination Plan Introduction
• 3. Coordinating with Other Providers

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What we will cover today

Colorado Department of Health Care Policy and Financing

• Compliments other assessments/care

plans currently in place

• Helps to identify gaps in existing services
• Identifies how RCCO care coordinator or

delegate can fill in gaps and assist with goal attainment

• SCP works off established written

protocols describing collaboration process

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How SCP Works with Other Care Plans

Colorado Department of Health Care Policy and Financing

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What other Assessments/Care Plans may exist?

Plan of Care or Assessment Who Receives this? Who assess?

ULTC 100.2 Any Medicaid client seeking waiver benefits Single Entry Point (SEP) or Community Centered Board (CCB) Case Manager Long Term Care “Service Plan” All Medicaid clients receiving Long Term Supports and Services and ALL HCBS waiver clients Single Entry Point (SEP) or Community Centered Board (CCB) Case Manager Developmental Disability Section Service Plan *Not required clients on HCBS-SLS, HCBS- DD, or HCBS-CES waiver Community Centered Board (CCB) Case Manager Supports Intensity Scale (SIS) clients on HCBS-SLS, HCBS- DD waiver Community Centered Board (CCB) Case Manager Intake / Initial Assessment For Behavioral Health Services Clients seeking or receiving behavioral health services Behavioral Health Organizations (BHOs) or Community Mental Health Centers (CMHCs)

Colorado Department of Health Care Policy and Financing

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Coordinating with Other Providers

• Written communication protocols,

established by RCCOs, assist in efficiently utilizing SCP

• Identifying and prioritizing shared

clients

• Outlines communication procedures,

roles, and responsibilities of cooperating agencies

Colorado Department of Health Care Policy and Financing

• 1. Continuously improving
• 2. Bi-directional and collaborative
• 3. Identification and prioritization of shared

clients

• 4. Understanding coordination activities
• 5. Regular contact and communication
• 6. Mutually agreed upon support function

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General Protocol Requirements

Colorado Department of Health Care Policy and Financing

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Protocol Network

RCCO

SEPs CCBs Home Health Hospitals SNFs Hospice BHOs Disability Orgs

Colorado Department of Health Care Policy and Financing

• Determine who is providing services
• Request and obtain copies of any service

plan, care plan or assessments

• Review existing information for SCP

applicable info

• Complete as much of SCP as possible
• Document info as appropriate on SCP

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Beneficiaries Receiving Case Management Services

Colorado Department of Health Care Policy and Financing

• If beneficiary has other case managers,

determine roles and responsibilities

• Determine with the client who is currently the best

(and most appropriate) point of contact and who is providing the majority of case management assistance

• Who does the client or representative feel most

comfortable talking to?

• Ask the client who they prefer to be their main point
• f contact to coordinate their care

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Determining Case Management Roles

Colorado Department of Health Care Policy and Financing

• RCCOs or delegate still expected to contact

client, introduce themselves and discuss services/supports client needs not currently being addressed

• RCCOs or delegate will talk with existing case

managers and client to identify who has most frequent contact w/client and who best serves as primary contact/case manager

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Clarifying Case Management Roles

Colorado Department of Health Care Policy and Financing

• Decide how you and other case managers will

work together and receive regular client updates

• Outline preferred communication strategies
• RCCO or delegate care coordinators still

responsible for:

• Completing and updating SCP regularly
• Coordinating client’s medical, behavioral, and social

services and supports

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Assigning Case Management Responsibility

Colorado Department of Health Care Policy and Financing

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What do you need from us?

• More trainings coming up
• What do you need training on?
• What ideas do you have for engaging clients?
• SCP workgroup
• Monthly meetings with RCCOs
• Care Coordinators encouraged to attend
• Help us Help You:
• Feedback on how SCP process is working

Colorado Department of Health Care Policy and Financing

• New Program Websites:
• For Clients:

https://www.colorado.gov/pacific/hcpf/accountable- care-collaborative-acc-medicare-medicaid-program

• For Providers: (click on and expand “Accountable Care

Collaborative: Medicare-Medicaid Program Training Materials”)

https://www.colorado.gov/pacific/hcpf/provider- training

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Program Resources

Colorado Department of Health Care Policy and Financing

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Questions?

Colorado Department of Health Care Policy and Financing

Van Wilson, MME Project Manager

Email: Van.Wilson@state.co.us Phone: 303-866-6352

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Contact Information

Improving health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources Colorado Department of Health Care Policy and Financing

Thank you!

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