Cal MediConnect Providers Summit June 23, 2015 California - - PowerPoint PPT Presentation

www.chcs.org

Cal MediConnect Providers Summit

June 23, 2015 California Department of Health Care Services (DHCS) Harbage Consulting Center for Health Care Strategies (CHCS)

Support made possible in part by The SCAN Foundation.

Welcome and Introductions

Harbage Representatives

Hilary Haycock President Rebecca Malberg von Loewenfeldt Director, LTSS Practice

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CHCS Representatives

Alexandra Kruse Senior Program Officer

DHCS Representatives

Hannah Katch Assistant Deputy Director for Health Care Delivery Systems

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About the Center for Health Care Strategies

A non-profit health policy resource center dedicated to advancing access, quality, and cost- effectiveness in publicly financed health care

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To bring together providers, health plans, plan delegates and others on the frontlines of implementing Cal MediConnect to:

• Give providers the tools and information they need

to deliver more integrated and coordinated care.

• Have practical conversations about care integration

and operational issues during early stages of implementation.

Summit Purpose

I. Welcoming Remarks II. Session #1: Best Practices for Care Coordination

• III. Session #2: Engaging Consumers in Care
• IV. Lunch: Plan Office Hours

V. Session #3: Integrating Home and Community-Based Services

• VI. Session #4: Leveraging Community Resources
• VII. Closing Session with DHCS

Summit Agenda

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René Seidel

Vice President of Programs and Operations The SCAN Foundation

Hannah Katch

Assistant Deputy Director, Health Care Delivery Systems California Department of Health Care Services

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Opening Remarks

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Best Practices for Care Coordination

Cal MediConnect Providers Summit June 23, 2015 Moderator: Alexandra Kruse, Senior Program Officer, CHCS

INTEGRATING BEHAVIORAL & PHYSICAL HEALTH: “WHOLE PERSON” CARE COORDINATION PETER CURRIE, PH.D INLAND EMPIRE HEALTH PLAN

• Today IEHP serves 1,100,000 members in government-

sponsored programs compared to 400,000 in 2009

• With Health Care Reform & Cal MediConnect, IEHP is projected

to grow to over 1,300,000 members by 2016: 1 in 4 IE Residents

Carve Out Of Behavioral Health: Unintended Consequences

 Behavioral and social determinants of health are major drivers of

health outcomes

 Separate funding streams for behavioral health created silos  Health plans and PCPs have not had much responsibility for BH  Medicaid benefits created “excluded diagnoses”

E.g., autism and other developmental disabilities

 County mental health programs were limited to serve only those

with severe mental health conditions – “Specialty Mental Health”

 Substance abuse was further segregated from mental health at the

state level and in most counties until recently -“Drug Medi Cal”

Riverside County Mortality Report (Provided Courtesy of RCDMH)

 206 adverse incidents reported

 January 2007 – May 2010  145 Deaths  US average life expectancy: 77.7 years  RCDMH average age at death:

 41.8 years  36 years less than the general population

 Natural causes: 46.8 years  Unnatural/unexpected causes: 38.8 years

 Deaths in older adults may be under-reported

Why IEHP Integrated BH

 Physical health and behavioral health (BH) care were

separate and disconnected

 Outpatient mental health services underutilized &

substance abuse treatment was nil

 IEHP had no influence over the BH network  Coordination of care – PCPs describe referring into the

“Black Hole”

 High cost of BH administrative services:

 50% of BH dollars reached the MBHO’s providers (2009)  Context – 95% of tax payer dollars

paid to IEHP reach IEHP Medical Providers

The BH Integration Plan

 Fully integrated BH program – “In House”  Streamline the coordination of physical and mental

health benefits

 Redirect MBHO admin/profit (50%)to fund expanded

BH services

 Directly contracted BH network – identify and support

best practices

 Eliminate reliance on vendors (MBHOs) for all BH

expertise including NCQA compliance

Preparation for Integration

 Infusing BH competency in all IEHP departments  In-house clinical expertise – clinical director, consulting

psychiatrist & BH care managers (LCSWs)

 Directly contract the BH network to ensure access  Leveraging web-based technology

 Online compiled EHR available to all BH providers  Required BH assessment/treatment plan sent securely

to IEHP BH care manager and the PCP

BH Integration at IEHP for Medicare: The Launch – Feb 1, 2010

 IEHP “Dual Choice” (Medi Medi) – foundation for CMC  One phone # access at IEHP for physical & mental health  BH call center: Triage & referral by BH care managers  Higher than average rate of pay for the initial evaluation:  Incentivize prompt access  Payment triggered by coordination of care TX report

web form – eliminating the “Black Hole”

 Added intensive outpatient programs (IOP)

BH Integration Results Applied to Cal MediConnect (CMC)Expansion

 Increase access to BH services – Cost neutral to plan  Medical cost-offsets for high-risk/high-cost populations  Improve coordination of physical & behavioral healthcare

through web: access to health record for BH providers & BH treatment reports through IEHP portal for PCPs

 IEHP’s BH network (private sector, FQHCs, county mental

health & CBOs): Access delays due to capacity is a concern

 Infusing BH services within primary care for complex

populations: e.g. pain/narcotic misuse

 Moving toward BH consultation for primary care where co-

location is not feasible

Massive Demand for BH Services: PCP Referrals Increase Dramatically in 2014/15

July-Sept 2013 Oct-Dec 2013 Jan-Mar 2014 Apr-June 2014 July-Sept 2014 Oct-Dec 2014 Fax 5 4 198 519 394 368 Web 6 11 740 2057 2756 3219 Total 11 15 938 2576 3150 3587 500 1000 1500 2000 2500 3000 3500 4000 Referral Volume

PCP Referrals Via Web & Fax

Report Period: July 2012 - December 2014

Pressure on Health Plans to Integrate Physical & Behavioral Health

 Download of BH benefits into the health plans

 January 1, 2014 Medicaid expansion of mental health  April 1, 2014 dual eligible pilot  September 15, 2014 EPSDT benefit for autism

 State direction & lessons from IEHP’s recent CMS audit

 Expectation that health plans have a care plan for

members that includes BH provider treatment plans

 Expectation that BH providers participate in

interdisciplinary care teams

Lessons from Riverside County Co-Location Pilot Applied to CMC

 Patients arrive to health care providers “fully integrated”

with physical and BH needs intertwined

 Health care providers in the IE operate mostly in silos that

limits their impact on overall health status

 Blaine Street County Mental Health and Rubidoux Public

Health Clinic bi-directional co-location pilot Learning

 People seek care where they are welcomed and comfortable  Rather than refer out to the “black hole” bring the

missing/needed care to where the population is

 IEHP’s “all in” investment: Behavioral Health Integration

Initiative (BHI-I)

What is the IEHP Behavioral Health Integration Initiative?

1.

A strategy for practice transformation

2.

Investment in infrastructure development and practice coaching to support integrated practice in partnership with key health care partners in San Bernardino & Riverside Counties

3.

The Pilots will impact 12 key Inland Empire health care providers and 33 clinics, including the public hospitals, county primary care, county behavioral health, private & non-profit primary care and behavioral health sites, a children’s clinic, a substance use treatment clinic, and a board and care center

4.

The intent: IEHP members receive integrated care from a team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide whole person care

Behavioral Health Integration Initiative (BHI-I) Framework

5 KEY AREAS OF CHANGE & IMPROVEMENT

• 1. Screening & assessment processes
• 2. Care planning
• 3. Service delivery practices
• 4. Population health management and data

infrastructure

• 5. Health promotion & patient experience of care

BHI-I Framework

Team Based Care Comprehensive Care Management and Coordination Health Information Technology Health Promotion and Self Management Achieving Improvement in Those Key Areas Requires Competency Development

Behavioral Health Integration: Platform for Population Healthcare

 Build & support health home array with “BH Inside”

Supporting provider partners who are already integrating care

to build out & refine what they have already begun

Linking best integration practices to achieve shared care plans

that live and breath and reflect the whole person

 Support new trans-disciplinary treatment models for

complex populations:

E.g., combining pain management, mental health

and substance abuse (SUD) to create a new pain/narcotic misuse treatment center

Example: Complex CMC Population - BH Integration to Address Two Public Health Crises:

1) Poorly treated chronic pain 2) Prescription drug abuse

IEHP Narcotics Claims Costs

$0.00 $200,000.00 $400,000.00 $600,000.00 $800,000.00 $1,000,000.00 $1,200,000.00 $1,400,000.00 $1,600,000.00 $1,800,000.00 $2,000,000.00 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Narcotics - All LOBs Total Paid

2014 2015

• Heroin

0.3M

• Meth

0.4M

• Crack

0.4M

• Hallucinogens 1.0M
• Cocaine

1.7M

• Tranquilizers

2.0M

• Pain Relievers

5.0M

• Marijuana

19.0M

• Tobacco 69.5M
• Alcohol

136M

Poorly Treated Chronic Pain

More than 116 million American adults suffer from pain, more than those affected by heart disease, cancer and diabetes combined

(Relieving Pain in America, Washington,DC: National Academies;2011)

Total related annual costs: $635 billion (Relieving Pain in America, Washington,DC: National

Academies;2011)

Poorly treated pain affecting approximately 75 million Americans

(American Pain Foundation. Annual report. 2006)

Poorly treated chronic pain negatively affects physical, psychological and social well being frequently leading to sleep disturbance, depression and anxiety (Argoff CE. The coexistence of neuropathic pain, sleep and psychiatric disorders: a novel

treatment approach. Colin J Pain. 2007;23(1):15-22)

Prescription Drug Abuse: Fastest Growing Substance Use Disorder (SUD)

Opioids have been used for thousands of years for analgesic properties (Deer ed. American Academy of Pain Medicine, Textbook 2013) 90% of patients being treated in pain management settings are receiving opioid therapy (Paulozzi et al. Increasing deaths from opioid

analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27)

In patients being treated for a chronic pain condition: 15% are concomitantly abusing prescription drugs and 35% are using illicit drugs (Manchikanti L. Prescription drug abuse: what is being done to address this

new drug epidemic? Pain Physician 2006;9(4): 287-321)

Prescription Drug Abuse

More than 6 million Americans are abusing prescription drugs, more than the number abusing cocaine, heroin, hallucinogens and inhalants combined. About 75% are in the opioid analgesic class (Deer ed. American Academy of Pain Medicine, Textbook 2013) The number of overdoses due to prescription opioids now surpasses both cocaine and heroin overdoses combined (Paulozzi et al.

Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27)

Cost related to prescription drug abuse: nearly $200 billion from medical costs, crimes involved and loss of productivity (Paulozzi et al.

Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006;15:(618-27)

Multidisciplinary Treatment

Medical Treatment Physical Therapy

Psychiatry Psychology SUD Treatment Alternative/ Complementary Treatments

Integrated Pain/Behavioral Health Treatment Pilot: Multidisciplinary Team

• Medical/Pain Specialists
• Medication management and opioid taper
• Interventional treatments, i.e. injections
• Psychologists and SUD specialists
• Physical reconditioning

Osteopathic manipulative treatment (OMT)

• Physical (PT) and Occupational (OT) Therapies
• Passive modalities (e.g., ultrasound, electrical, stimulation, massage)
• Neurophysiology education
• Alternative/Complimentary
• Chiropractic care
• Naturopathic/Homeopathic treatments, hydrotherapy
• Diet coaching
• Mindfulness/Meditation

Integration In California: Agenda for 2015/16

 The Impact of the ACA on California

 From silos to accountable organizations  New benefits require changes in responsibility  Expect movement from “carve-out” to “carve-in” funding

 Health Home Array to add Behavioral Health Homes

 Promoting innovation county by county  Piloting new BH integration models in primary care  New behavioral health home models for SMI population served

by county mental health and innovative wrap around programs (e.g. telecare)

Achieving the Triple Aim by integrating the social and behavioral determinants of health into health care payment and delivery systems

Cal-MediConnect Provider Summit

Best Practices For Care Coordination Deborah Miller

Vice President, Healthcare Services Molina Healthcare of California June 23, 2015

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• Helping members/families access medical benefits and

services (LTSS, LTC)

• At the right time, place and cost
• Based on assessed needs: behavioral health, medical,

psychosocial, functional status

• Based on member’s preferences and willingness to

participate

• In concert with PCPs, specialists, LTSS providers and
• ther interdisciplinary participants and providers

Molina Care Coordination

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Care Coordination-Other Provider Types

• Hospitals
• Home health, hospice, palliative care
• SNF and LTC, board and care facilities
• Urgent care providers
• Behavioral health providers, county agencies
• IHSS, MSSP, CBAS
• Dialysis center staff
• Independent living centers

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Care Coordination

Most effective with provider involvement Common reasons to contact physician:

• Invite to the interdisciplinary care team meeting
• Obtain PCP involvement in care coordination
• Share medication concerns, pharmacist input
• Giving/getting information - change in health status
• Share assessment information - care plan development,

psychosocial issues, LTSS, plan care coordination

• Work with physician extender when physician unable to

participate directly in ICT

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IPAs and Medical Groups

• Those with MSO or care management departments - very

receptive to participating in care coordination

• Will often send their case manager to the ICT
• Will often invite plan’s CM to their ICT
• Receptive to contributing to care plan, sharing member

address/phone number, other relevant information

• Appreciate our field work with member, care transitions,

follow up with member, LTSS service coordination

• JOMs - focus on what can be improved
• Plans want more access to group/IPA EMR

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Interdisciplinary Care Team

PCP/Specialist involvement:

• Becoming more common
• Now more receptive to ICT recommendations
• IPA medical assistant is often the path to access the physician
• PCP more likely to accept brief phone call for consult than

attend a formal ICT

• Physician ICT involvement is brief, can be formal or informal
• Respect PCP’s time

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Frank’s Story

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Frank’s Interdisciplinary Team

• Frank (member centric)
• RN care manager - Molina
• Community Connector - Molina
• PCP - medical group, IPA, direct
• Physician specialists
• Medical director(s) - Molina
• Director of LTSS-Molina
• Dentist
• Frank’s wife
• ILS - independent living center representative
• Ramp builder
• IHSS liaison

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What did Frank need/want?

• Access to care - Physician that can manage complex care
• Independent transfers - in and out of bed
• Fewer UTIs
• Healed skin wounds, no more pressure sores
• Transportation to medical appointments
• To go back to school
• Safe access to his apartment-ramp

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What did Frank need/want?

• To link family with services (dental, medical)
• To take a shower safely, regularly
• Dentures
• To give up
• To die
• A transplant
• To live

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What did Frank Get? (so far)

• A caring involved PCP, access to specialists
• A bed, trapeze - Independence
• Dental care - access
• Incontinence supplies - fewer UTIs
• Functional wheelchair - Independence
• On waiting list for better housing
• Assessment for transplant - access to care

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What Else Did Frank Get?

• Interdisciplinary team expertise
• Advocacy- psychological support
• New perspective - motivation
• The will to live
• Hope for a better future
• Better Quality of Life through interdisciplinary care

coordination

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Demara Nuzum, RN Vice President of Medical Management

• Breadth and Depth of Network
• Largest non-Kaiser provider of managed care services in

S.B. and Riverside counties ~22%

• Exclusive PCPs represent over 87% of enrollment
• 3-5 year exclusivity terms with 11 year average tenure
• Strong Payer Relationships
• Global risk with 8/9 senior and 3/7 commercial plans
• Private label PPO/HMO commercial ACO product
• Covered California HMO provider
• Other Commercial ACO products pending

Cities/Towns with NAMM Physician Presence Represents Area with Negligible Population Density NAMM Primary Admitting Hospitals

NAMM CA Overview MA & Duals 67,000 Commercial 160,000 Exchange 12,000 Insurance License Limited Knox-Keene Network Statistics 15 IPAs, 575 PCPs IPA Relationships 1 Managed, 14 Owned Key Relationships Aetna, Blue Shield, United, Cigna, Humana, Anthem, SCAN, Health Net, Care 1st, IEHP, Sharp

IPAs:

• PrimeCare Medical Group of Chino Valley, Inc

(50%)

• Primary Care Assoc. Medical Group, Inc
• Mercy Physicians Medical Group, Inc

(Managed) Owned Groups:

• Redlands Family Practice Medical Group, Inc.
• Physician Partners Medical Group

Other NAMM Managed/Owned Entities

North American Medical Management, California, Inc.

Owned IPAs:

• Coachella Valley Physicians of PrimeCare, Inc.
• PrimeCare of Citrus Valley, Inc. (80%)
• PrimeCare of Corona, Inc.
• PrimeCare of Hemet Valley, Inc.
• PrimeCare of Inland Valley, Inc.
• PrimeCare of Moreno Valley, Inc.
• PrimeCare of Redlands, Inc.
• PrimeCare of Riverside, Inc.
• PrimeCare of San Bernardino, Inc.
• PrimeCare of Sun City, Inc.
• PrimeCare of Temecula, Inc.
• Valley Physicians Network, Inc. (80%)
• Premier Choice ACO, Inc.

PrimeCare Medical Network, Inc Knox-Keene Your Health Options Insurance Services, Inc.

Scripps IDN Management, LLC (JV) MDOps, Inc.

MSO Services

• Dr. Tarek Mahdi

President Riverside Family Physicians

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Questions and Discussion

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Engaging Consumers in Care

Cal MediConnect Providers Summit June 23, 2015 Moderator: Hilary Haycock, President, Harbage

Jeanna Kendrick Senior Director of Care Management Inland Empire Health Plan Gilbert Sauceda Program Manager Riverside County, HICAP Kristine Loomis In-Home Supportive Services (IHSS) Client and Advocate

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Questions and Discussion

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Lunch: Cal MediConnect Plan Office Hours

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Integrating Home and Community-Based Services

Cal MediConnect Providers Summit June 23, 2015 Moderator: Rebecca von Lowenfeldt, Director of LTSS Practice, Harbage Consulting

Ben Jauregui Manager of LTSS Inland Empire Health Plan

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Long-Term Services and Supports

Promoting Home and Community-Based Options LTSS

Objective: Design policies, procedures, and infrastructure required to coordinate LTC and HCBS for our members.

CCI Workgroups

• MSSP Super Workgroup
• IHSS Super Workgroup
• Duals/CCI Data Sharing
• Gaps/Optional Services
• External Relationships
• LTC Program Design
• Coordinating and Integrating

Member Care

• In-House LTSS Program

Design

Long-Term Services and Supports

• Long-Term Care
• Home and Community-Based Services
• In-Home Supportive Services
• Multi-Purpose Senior Services Program
• Community-Based Adult Services

New Requirements

Membership Utilizing LTSS

Units Established

• Long-Term Care Unit established in 2013 in

Utilization Management Department

– 19 nurses and coordinators

• LTSS Unit established in 2014 in Care

Management Department

– 3 nurses, 1 social worker, 2 coordinators

LTSS Manager CBAS Coordinator CBAS Nurse CBAS Nurse IHSS/MSSP Coordinator IHSS/MSSP Nurse Care Manager IHSS/MSSP Social Worker

LTSS Unit

Community-Based Adult Services In-Home Supportive Services and Multi-purpose Senior Services Program

• Identifies potential members for LTSS through

referrals from care managers, encounter inpatient admissions, outpatient referrals, and provider referrals

• Assist members in accessing LTSS benefits
• Coordinate care between IEHP/LTSS provider/

county/community-based organizations

• Identify members needing a higher level of care or

formal interdisciplinary care team meeting

LTSS Unit Activities

LTSS Disability Program Health Education Health Navigators Transition

• f Care

Behavioral Health

Support Services

Community Resources County Mental Health Home Delivered Meals Home

Modifications

Caregiver Resources

Transportation

Resources

• LTSS social worker – links members to critical

resources to prevent or delay SNF

• Disability Program – links members to

community resources

– Identify and build relationships with CBOs that serve seniors and people with disabilities – Link members to CBOs – On-line community resource guide via 2-1-1

Support Services

Challenges

• Educating staff about social needs and services
• Establishing relationships with providers
• Critical to listen in order to understand their

regulations, abilities, limitations and concerns

• Balance between service demand, having

resources in place and revenue flows

• Staffing is difficult because of fluid timelines

• 64 year old male living alone. Physical and cognitive disabilities.

Denied IHSS twice. Care manager referred member to IHSS unit and care manager assisted with application. Member approved for IHSS.

• 56 year old female receiving 60 hours a month. After surgical

procedure needed temporary raise in IHSS hours. LTSS unit coordinated with the county to temporarily increase hours to 209.

• 50 year old male, referred by county MH to CBAS center. Before

CBAS, was homeless, several psych inpatient stays, several B&C and R&B. Several ER visits. Attends CBAS 4 days a week regularly and living at same B&C for last 6 months - no ER visits.

Success Stories

Questions or Comments?

Promoting Home and Community-Based Options LTSS

John A. Roohan, M.D.

Medical Director, Long Term Care Molina Healthcare of California June 23, 2015

Cal-MediConnect Providers Summit

Coordinating Care in Institutional-based Long-Term Services and Supports

Overview of MHC MMP Long Term Care (LTC) Members in IE

• Molina currently has approximately 800 LTC members

participating in the CCI program who reside in LTC facilities in the Inland Empire

• 95 contracted LTC facilities in both IE counties

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Aligning with DHCS Stated Goals of the CCI

4

Improve Access to Care Promote Person- Centered Planning Promote Independence in Community Right Care Right Time Right Place Cost Savings for State and Federal Government

Aligning with DHCS Stated Goals of the CCI

4

Improve Access to Care Promote Person- Centered Planning Promote Independence in Community Right Care Right Time Right Place Cost Savings for State and Federal Government

Improving Access to primary care in LTC setting

• Molina is committed to ensure that our members residing in LTC have

access to primary care physician services.

• For our LTC members who have not opted out from the Medicare portion
• f CCI: Molina contracts with community based physicians who are

willing and able to fulfill the role of primary care physician.

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Molina has developed a document to outline our expectations and requirements for primary care physicians whose assigned members reside in nursing facilities:

Physician Responsibilities in a Nursing Facility

• Comprehensive Medical Case Management: participation to ensure coordination
• f specialty, ancillary services
• Health Promotion and Disease Prevention; Preventative Health Services: age,

gender, and condition specific screenings, health education and promotion

• Standards for timely access to care: state-approved contractual standards
• Participation in Quality Improvement and Performance programs: HEDIS,

Annual Comprehensive Evaluations (ACE), submission of accurate and timely data for risk adjustment

• Provide medically necessary visits at regular intervals, as appropriate for the

member’s medical needs and level of care required

• Participation in all coordination efforts: ICT meetings (scheduled and ad hoc),

transitions of care program, identification of potential members who would be able to transition back into the community

• Grievance program and Reporting: timely, accurate responses

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Aligning with DHCS Stated Goals of the CCI

4

Improve Access to Care Promote Person- Centered Planning Promote Independence in Community Right Care Right Time Right Place Cost Savings for State and Federal Government

Interdisciplinary Care Team (ICT) Meetings

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ICT Composition

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The ICT consists of the member, the member’s family and/or caregiver, and internal and external stakeholders. Example stakeholders include, but are not limited to:

• Case Managers
• Medical Director
• CAM Staff
• Community Connectors
• Social Worker/ Behavioral

Health Specialist

• Pharmacist
• Physicians
• Facilities
• Home Health Care
• Long-Term Care
• Long-Term Services and

Supports Internal Stakeholders External Stakeholders Member

Cases to be presented in an ICT meeting are identified through:

• Historical data and predictive software to identify

highest risk members

• Health Risk Assessments (HRAs)
• Recent transition(s) of care
• Member or surrogate decision maker request
• Facility or provider request

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What are some of the goals of ICTs?

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• Develop care plans which focus on individual needs for members and their

families

• Improve care by increasing coordination of services, including long term

services and supports (LTSS)

• Encourage innovation around difficult problems
• Serve members of diverse cultural backgrounds
• Use time and resources more efficiently
• Facilitate shift in emphasis from acute, episodic care to long-term and

preventative care

• Promote high quality, comprehensive, and cost-effective member care

Shared Process

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All ICT members, including the member or family, will complete the following activities together:

• Identify the member’s main health concern
• Clarify the primary guidance or information being sought from the ICT
• Discuss member’s:
• Relevant medical conditions
• Behavioral health conditions
• Medications
• Functional status
• Family or resource status
• Environment
• Existing care plan and interventions already implemented

Shared Process (continued)

• Define and expand any problems
• Develop and evaluate potential solutions or management plans. Each team

member contributes his/her own unique perspective.

• Decide on goals
• Summarize the plan and agree on distribution of tasks across team

members

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ICT Follow-up

• Care manager is responsible to:
• Distribute the updated care plan summary to internal and external

stakeholders

• Ensure proper implementation of the care plan and to identify concerns
• r barriers
• Follow-up on a regular basis with the member, family, and facility

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Aligning with DHCS Stated Goals of the CCI

4

Improve Access to Care Promote Person- Centered Planning Promote Independence in Community Right Care Right Time Right Place Cost Savings for State and Federal Government

A success story: transitioning back to the community level of care from LTC setting

• Mary is a 65 year old female resident of the Inland Empire who was

hospitalized for osteomyelitis (bone infection).

• She received treatment in an acute hospital and was transferred to a SNF for

skilled care and IV antibiotics. The member then transitioned from skilled to custodial level of care due to her inability to return home related to her medical and physical needs.

• She had a history of diabetes, Parkinson’s disease, and depression.
• Member subsequently was enrolled as a MMP member with Molina.
• During her stay at the SNF, the member expressed her desire to return to the
• community. However she no longer had access to affordable housing; so it was

especially challenging for the team at the facility to assist her.

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Transition story (continued):

• Through the ICT process, a referral was made to the California

Community Transitions (CCT) organization to assist Mary to return to the community.

• The Molina case manager was able to work collaboratively with

the member along with CCT and the SNF in order to ensure the member had the services they needed.

• The Molina Long Term Services and Supports (LTSS) Liaison

also worked with the County IHSS program to ensure that the member was assessed for IHSS while at the SNF. – IHSS was able to complete an expedited initial assessment and then follow up and assess her again upon discharge. – Expedited assessments through IHSS are a new benefit through CCI.

• The CCT program was able to assist with housing, utilities, stove,

refrigerator, DME and even groceries.

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Transition story (continued):

• As a result of this collaborative effort, Mary was able to transition into

her own apartment on May 1, 2015.

• The Molina case manager, Molina LTSS liaison, the CCT organization,

SNF staff, DME vendor, IHSS, and the member’s family all worked together to make sure that the members needs were met.

• The Molina case manager continues to follow up with Mary and her

family at least weekly. He has been assisting to coordinate her follow up appointments, requests for additional DME, and specialists.

• She has expressed how happy she is to be living independently once

again with the help of everyone involved.

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Multiple challenges to transitioning from LTC back to the community

• Mental health and substance abuse issues
• Chronic homelessness
• Short term homelessness: access to affordable housing in general,

affordable housing lost after members are in LTC (e.g. lose senior apartment during acute and rehabilitative care)

• Lack of functioning family or social support network
• High complexity medical needs:

– Polypharmacy – Homebound care – Wound care

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Looking ahead…

1. Further strengthen our partnership with key providers like yourselves by ensuring we have provided you with the resources & support you need to effectively care for our members 2. Identify creative/collaborative strategies to overcome barriers to delivery

• f cost effective, quality care

3. By doing so, encourage retention of members in the CMC program, as well as re-enrollment

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Darren Gray Social Worker Loma Linda University Medical Center CBAS Adult Day Health Services

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Questions and Discussion

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Leveraging Community Resources

Cal MediConnect Providers Summit June 23, 2015 Moderator: Alexandra Kruse, Senior Program Officer, CHCS

Disability Program

ACCESS HEALTHCARE SERVICES COMMUNICATION

Mission

B A R R I E R UNEVEN PLAYING FIELD

1989

THE FIRST BEST BUDDIES CHAPTER WAS CREATED

ACCESS

Provider office Accessibility information readily available for Members

COMMUNICATION

Sign Language Interpreter Services

IEHP Benefits

HEALTH CARE SERVICES

PARTNERSHIPS

950+

Community Based Organizations available to assist IEHP’s seniors and persons with disabilities

RESOURCES

Disability Program

683

Cases created to date since November 2013

1,708

Referrals to Community Based Organizations provided to Members to date since November 2013

COLLABORATION

BASIC NEEDS

ASSISTIVE TECHNOLOGY

TRANSPORTATION

EMPLOYMENT

CULTURAL COMPETENCY

Disabled Person

Person with a Disability

Persons with Disabilities Workgroup

Outreach

Inland Empire Disabilities Collaborative

QUESTIONS?

Service Center for Independent Life 107 S Spring Street, Claremont, CA 9171 (909) 621-6722 – Voice (909) 962-7035 – Video Phone Rolling Start, Inc. 1955 Hunts Lane #101, San Bernardino, CA 92408 (909) 890-9516 – Voice (909) 252-7622 – Video Phone Community Access Center 6848 Magnolia Avenue, Suite 150, Riverside, CA 92506 (951) 274-0358 - Voice (951) 274-0834 - Video Phone

Contact us

• Gabriel Uribe
• Telephone: 909-296-3539
• Email: uribe@iehp.org

THANK YOU

Paul Van Doren Executive Director Community Access Center

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Questions and Discussion

www.chcs.org

Closing Session: Q&A and Key Takeaways

Cal MediConnect Providers Summit June 23, 2015 Moderator: Alexandra Kruse, Senior Program Officer, CHCS Panelist: Hannah Katch, Assistant Deputy Director for Health Care Delivery Systems, DHCS

Cal MediConnect Resources

• To access any of the PowerPoints or other materials you

saw today visit www.calduals.org/summit and click ‘Summit Materials.’

• If you have more general questions about Cal

MediConnect or the Coordinated Care Initiative, send an email to info@calduals.org.

• For more provider-specific information, including fact

sheets and presentations, visit www.calduals.org/providers.

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Visit CHCS.org to…

• Download practical resources to improve the quality and

cost-effectiveness of Medicaid services

• Subscribe to CHCS e-mail updates to learn about new

programs and resources

• Learn about cutting-edge efforts to improve care for

Medicaid’s highest-need, highest-cost beneficiaries

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www.chcs.org