Cal MediConnect: Care Management & Collaboration to Achieve Patient- Centered Care for Duals Eligible Beneficiaries Living with Mental Illness Clayton Chau, MD, PhD, Senior Medical Director, Health Services, L.A. Care Associate Clinical Professor of Psychiatry, UCI cchau@lacare.org Yvette Willock, LCSW, MA, Program Manager, LA CountyDepartment of Mental Health, Health Agency Ywillock@dmh.lacounty.gov Lamar Smith, PsyD, Clinical Director, Behavioral Health Services, L.A. Care Lsmith2@lacare.org
Disclosure Ms Willock, Drs. Chau and Smith have no Relevant financial relationships with commercial interests to disclose. | 2
Overview of Cal MediConnect Care coordination across agencies – successes and challenges L.A. Care’s Integrated Care Management model | 3
Improve the health of the population Enhance the patient experience of care (including quality, access, and reliability) Reduce the per capita cost of total healthcare
Overview of Cal MediConnect | 5
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Care coordination across agencies – successes and challenges | 11
Health lth Plans LAC DMH Health lth Plans s Care e Behavior vioral al Coor ordina ination tion Health lth Team Team LAC DMH Provi Pr vider ders
Match Lists Client Treatment Plan Request Logs Client Treatment Plan Submission to Health Plans Individual Care Plan (ICP) developed by Health Plan Interdisciplinary Care Team (ICT) review of ICP Ad Hoc ICTs for on-going Care Coordination Activities
Full understanding of the Consistent Responses to CTP Requests Confidentiality Consistent Responses to requests for Care Coordination outside of own System of Care
Increase in CTP Submissions resulting in an increase in the development of comprehensive CTPs Enhanced service delivery due to collaboration between DMH Providers Health Plans
L.A. Care’s Integrated Care Management model | 16
Key Components of Case Management ( Rapp & Goscha, 2004) 1. Case managers participate in delivering services. 2. Whenever possible, case management services are provided in the community and in a person’s natural environment. 3. Providers use a team approach to support consumers and each other. 4. There is a focus on building natural community connections (e.g., landlords, employers, ministers, neighbors, teachers, community centers, and coaches). 5. Case managers have access to quality supervision. 6. Caseload size is small enough to allow for higher frequency and quality of contact. 7. When possible, case management services are not time-limited for those with intensive needs. 8. Consumers always have access to crisis response services. 9. Self-determination and consumer choice are 17
Integrated Care Management Concept To assure that each member/patient/client receives timely, effective, efficient care, at the appropriate level and with appropriate resources, and to provide psychosocial assessment and intervention for members and families with social, psychological and/or environmental needs. These needs may be related to future or current health status, diagnosis, treatment and discharge Goals: Member receives the right care in the right place at the right time Improvement in the doctor-patient dyadic relationship 18
Good ideas that DON’T WORK Screening in primary care without adequate treatment / follow-up • 20 years of negative studies • “You can’t fatten a cow by weighing it.” Provider education • Knowledge is not enough • Providers need systems and help to do the right thing Telephone-based case management 16 negative studies with ~ 300,000 Medicare recipients • McCall N, Cromwell J: N Engl J Med 2011;365:1704-12. • Peikes D et al: JAMA. 2009;301(6):603-618
Member Profile Cancer Infectious Diseases Chronic Physical 10-20% Pain 10-40% 25-50% Mental Health / Neurologic Substance Abuse Disorders Smoking, Obesity, Physical Inactivity 10-20% 40-70% Heart Disease Diabetes 10-30% 10-30%
Integrated Care Integrated Fragmented System Care Multiple providers Accountable medical home No coordination Coordinated care for patients with complex Lack of patient focus needs Inadequate Patient-centered care information sharing Information exchange No accountability Performance measures Unaligned payment Incentives/aligned financing 21
The Care Team Team Member Role • Member Makes decisions about the provider, location, and services that support their recovery • Receives education that empowers them to self-manage and remain independent • Primary Care Provider Maintains primary responsibility for oversight of the member’s care, including behavioral health and physical (PCP or Behavioral Health health services • Treatment Providers) May be a behavioral or physical health provider • Care Manager Serves as the primary point of contact for the member • (Nurse or licensed Behavioral Coordinates all referrals and service delivery • Health Clinician) Facilitates ongoing assessment and treatment planning • Provides whole person services to meet the member’s needs • Social Worker Conducts ongoing reviews of the member’s service utilization, care gaps, and predictive modeling to identify duplication of services or needs for additional support (e.g., high risk, high utilizers) • Supports the clinical team in connecting high needs members to the community resources and services they need • Care Coordinator Facilitates ongoing communication between all providers and other stakeholders (e.g., jails, Child Safety, Health Plans, Find a member) • Follows up with the clinical team on care gap notifications, needs for preventive care • Peer Specialist Provide hands on face-to-face support such as attending appointments • Important liaison • Assist member in identifying barriers • Transition of Care agent • Other team members Provide specialized knowledge and support • (Pharmacist, Health Educator, Provide specialized input into care plan • Disease Management, Help team members find specialists when needed Nutritionist/Dietician, MLTSS worker) 22
CORE PRINCIPLES • Specify targeted members – risk levels • Transdisciplinary team • Comprehensive evaluation • PCP + Member dyad is at the center • Motivation and activation • Assertive and flexible • Meeting the members where they are at • Shared responsibilities but member driven • Individualized services: strength based • Self management is the end goal • Ultimately about r ecovery, r esiliency and (self-) r eliance
Discussion | 24
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