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14 - DSS Presentation to Health and Human Services Committees - Jan 2015

Friday, January 16, 2015 1:05 PM

Department of Social Services Update

Senate Health and Human Services Committee January 14, 2015

DSS

Slrlll Fllllllel · 1111th Dallll'I FNIIIIIIIII IN

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Department of Social Services

I SECRETARY I

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ADMINISTRATION FINANCE LEGAL SERVICES DIVISION OF ECONOMIC ASSISTANCE MEDICAL AND ADULT SERVICES DIVISION OF MEDICAL SERVICES DIVISION OF ADULT SERVICES & AGING CHILDREN'S SERVICES DIVISION OF CHILD SUPPORT DIVISION OF CHILD PROTECTION SERVICES DIVISION OF CHILD CARE SERVICES BEHAVIORAL HEAL TH HUMAN SERVICES CENTER DIVISION OF BEHAVIORAL HEALTH

BOARD OF COUNSELOR ; ·- ' EXAMINERS

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BOARD OF PSYCHOLOGY ;

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EXAMINERS

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' BOARD OF ADDICTION & , : PREVENTION

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PROFESSIONALS :

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Department of Social Services

Vision: Strong Families - South Dakota's

Foundation & Our Future

Mission: Strengthening and suppotting individuals and

families by promoting cost effective and comprehensive services in connection with our pattners that foster independent and healthy families.

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Guidin Princi les:

• We believe families have the right to be safe and secure

. We believe in providing opportunities and choices that support the needs

• f families through available and accessible services.

We believe in collaborative communications, teamwork, partnerships and trust for essential family services. We believe in respecting individual and cultural differences by treating people with dignitY, fairness and respect. We believe in focusinq on results, quality and continuous improvement and on using state-or-the-art technology to be more efficient and effective. We believe in professional and well-trained staff who are competent, accountable and empowered. We believe in providing qualitY, timely customer service through the "no wrong door" approach.

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Strate ic Plan Goals:

• Goal 1: Ensure access to services for our customers.
• Provide opportunities to access services.
• Services and programs are needs driven, customer

responsive and culturally relative.

• Goal 2: Protect individuals from abuse, neglect and

exploitation.

• Provide preventative services and supports for individuals to

be safe.

• Provide services to individuals who have been abused

neglected or exploited.

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Strate ic Plan Goals:

• Goal 3: Foster partnerships to leverage resources for
• ur customers.
• Encourage and support partnerships to provide cost

effective services.

• Support Tribal government efforts to administer

programs and services.

• Goal 4: Improve outcomes through continuous

quality improvement.

• Ensure the Department helps individuals and families

achieve meaningful outcomes.

• Implement continuous quality improvements to

achieve desired outcomes.

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Strate ic Plan Goals:

• Goal 5: Strengthen and align human resources to

meet our mission.

• Enhance recruitment and retention efforts that result

in _a ".Vorkforce that implements the Department's m1ss1

• n.
• Provide employees with the knowledge and

resources for quality performance.

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Strategic Plan Aecom lishments/Ke Initiatives:

• Continued implementation of the Affordable Care Act
• Health Homes
• Continued development of services for individuals with

behavioral health needs

• Money Follows the Person
• Regulatory changes related to individuals served in

assisted living home and community based settings

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Affordable Care Act

Effective January 1, 2014 :

• Changes in the basis for determining Medicaid eligibility.

Use of gross income vs. net income as the basis for determining Medicaid eligibility nationally.

• States must verify information electronically.
• No changes to long term care eligibility.

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Affordable Care Act

• Changes to the process applicants use to apply.
• In addition to how people apply for Medicaid, applicants must be

able to apply on-line directly to the State Medicaid Agency or to the Federally Facilitated Marketplace (FFM) or a State established Exchange.

• South Dakota is utilizing the Federally Facilitated Marketplace.
• State Medicaid agencies must be able to receive applications from

the FFM and send applications to the FFM.

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Affordable Care Act

First open enrollment period January 1, 2014 - March 30, 2014.*

• During open enrollment 24,147 South Dakotans applied to the FFM.
• 5,423 individuals referred to DSS Medicaid.
• 2,845 (52%) already enrolled in SD Medicaid.
• 2,041 (38%) not eligible for SD Medicaid.
• Did not meet income guidelines.
• No coverage group.
• 537 (10%) of applicants determined to be eligible for

Medicaid.

• 411 Children - 76.5%.
• 126 Adults - 23.5%.

*Extension to April 15, 2014 for applicants that started an application by March 30 but had problems with FFM processing. 11

Affordable Care Act

• Implementation Challenges:
• During first open enrollment period individuals caught in "loop" due to

FFM programming issues.

• FFM not able to identify duplicate applications referred back to the

FFM from DSS so process started over.

• CMS corrected the looping error in late March 2014.
• CMS unable to send account transfers real time creating a backlog of

applications.

• Inability to send real time transfers resulted in backlog of applications

being submitted to DSS. CMS sent states lists of individuals in late December 2013.

• South Dakota outreached these individuals "stuck" at the FFM to
• btain application information and determine Medicaid eligibility so

that those ineligible for Medicaid could enroll in Qualified Health Plans.

• South Dakota one of the first states to resolve backlog and CMS

corrected this issue in April 2014

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Affordable Care Act

• Implementation Challenges:
• Shift in children from CH IP to Medicaid
• States expected to see some churn in Medicaid and CHIP eligible as

a result of the converted federal poverty levels .

• In January 2014- South Dakota began seeing larger than anticipated

shift of children from CHIP where services are paid at the enhanced match rate to Medicaid where services are funded at the regular FMAP rate.

• Discussions with CMS resulted in adjusting South Dakota's federal

poverty levels. Re-evaluated eligibility determination for all children retroactively to January resulting in shift of 2,900 children back to CHIP where services are paid at the higher match rate.

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Affordable Care Act

Second open enrollment period November 15, 2014- February 15, 2015.

• November 15, 2014 - December 29, 2014 - YTD
• During open enrollment 13,400 South Dakotans applied to the FFM.
• 2,256 individuals referred to DSS Medicaid.
• 1,647 (73%) completed determinations.
• 647 (39%)- already enrolled in SD Medicaid.
• 756 (46%)- not eligible for SD Medicaid.
• Did not meet income guidelines

.

• No coverage group.
• 244 (15%) of applicants determined to be found eligible for

Medicaid.

• 213 Children - 87%.
• 31 Adults - 13%.
• Remainder (609) being evaluated for eligibility determination.

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Affordable Care Act

• Implementation Challenges:
• While income guidelines standardized nationally, FFM still not

differentiating state specific coverage groups resulting in a number of applications sent to DSS for individuals not eligible for Medicaid.

• Medicaid eligibility check feature not yet implemented resulting in large

number of application sent to DSS for individuals already enrolled in SD

• Medicaid. DSS required to process and send results back to the FFM.
• Federal requirements continue to change.

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Health Homes

Health Homes provide enhanced health care services to individuals with high-cost chronic conditions or serious mental illnesses to increase health outcomes and reduce costs related to uncoordinated care.

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Health Homes Background

Medicaid Solutions Work Group

• Established during 2011 Legislative Session; report

issued November 2011

• Maintain quality services and control costs
• Health Homes were established by the Affordable Care

Act

• 2 year demonstration opportunity with enhanced

federal funding

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Health Homes Background

• Stakeholder work group established by DSS in April,

2012

• Included providers from large health care systems,

I HS, Mental Health Centers, etc.

• Examined data
• Developed South Dakota's Health Home model and

processes

• Now assists with ongoing implementation
• Medicaid State Plan amendment approved July, 2013

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Health Homes

Health Homes are not:

• Home health
• In-home care
• A place where people live and receive care
• Patient Centered Medical Home

Health Homes - provide person-centered care to achieve

improved outcomes and reduced costs

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Health Homes

Health Home Eligibility

• Medicaid recipients who have:
• Two or more chronic conditions OR one chronic and at risk for

another (Defined separately):

• Chronic conditions include: Mental illness, substance abuse,

asthma, COPD, diabetes, heart disease, hypertension, obesity, musculoskeletal, and neck and back disorders

• At risk conditions include: Pre-diabetes, tobacco use, cancer,

hypercholesterolemia, depression, and use of multiple medications (6 or more classes of drugs)

• One severe mental illness or emotional disturbance
• 83% of the 5% highest cost, highest risk group are eligible for Health

Homes

DSS.

Stro g Fam Has -South Dakota's Foundation and ur Future 20

Health Home Services Core Services

• Comprehensive Care Management
• Care Coordination
• Health Promotion
• Comprehensive Transitional Care After Hospitalizations
• Patient and Family Support
• Referral to community and support services

There are two types of Health Homes in South Dakota

• Primary Care
• Behavioral Health

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Health Homes

Primary Care

• Primary Care Physicians
• PAs
• Advanced Practice Nurses
• Federally Qualified Health Center
• Rural Health Clinic
• Clinic Group Practice
• IHS

Health Care Team

• Care coordinator
• Chiropractor
• Pharmacists
• Support staff

Behavioral Health

• Mental Health Providers

Working in Community Mental Health Centers

• Health Coach
• Other appropriate services

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Health Homes

Provider Reimbursement

• Per member, per month for 6 core Health Home services
• Eligible Medicaid recipients are placed into one of four tiers,

based on their need for services

• Need for services is based on historical claims and

diagnosis information, using a standardized tool normed against the Medicaid population

• Tier 1- half the population, have average risk of utilization,

can opt in to participate

• Tiers 2-4- have progressively higher risk of health care

utilization, can opt out of program

• Non Health Home services are paid on current fee-for-service

basis

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Case Studies: 4 Tier Model for Primary Care Provider Health Home

. Tier 1 Member

• Tier 2 Member
• Tier 3 Member

44-year-old female 49-year old male 35-year-old female $4,727 Total Spend $11 ,724 Total $18,139 Total Spend $714 Rx spend, 1 Spend $5,580 Rx Spend, $4,878 Rx spend, 13.3 Rx/mo, 16 Rx/month, 2 chronic drug 4.8 Rx/mo, 8 ch ronic drug classes classes chronic drug 2 ER Visits 1 ER Visit classes 2 IP Admits including 1 0 IP Admits

1 ER Visit

readmit, $4,517 IP 4 physicians

1 IP Admit, $3,042

spend Hx of substance abuse, IP spend 1 4 physicians smoker, low back 5 physicians providing E&M Hx of hypertension , services high cholesterol, Hx of anxiety, asthma, low back, COPD, COPD, depression, asthma high cholesterol, low back, MSK, diabetes

DSS.

Stro g Fam Has -South Dakota's Foundation and ur Future

. Tier 4

Member

45-year-old female $49,321 Total Spend $2,359 Rx Spend, 7.3 Rx/mo, 12 chronic drug classes 25 ER Visits 10 IP Admits including 6 readmits, $22,224 IP spend 24 physicians Hx of anxiety, asthma, epilepsy, hypertension, low back, MSK, sleep disorder, substance abuse, smoker, chronic pain, depression

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Case Studies: 4 Tier Model for Behavioral Health Health Home

• Tier 1 Member
• Tier 2 Member
• Tier 3 Member
• Tier 4 Member

44-year-old female $49,387 total spend

25 year old female $4642 tot al spend $113 Rx spend, 1.5 rx/mo, 1 • chronic drug group 0 ER Visits 0 IP Admits 7 physicians History of ADHD, Depression. and Low Back Pain.

43 year old female $18,393 Total Spend

• $4,493 Rx spend,

6.1 Rx/mo, 8 chronic drug classes 2 ER Visit 1 IP Admit, $2,757 IP

• spend

16 physicians Hx of Bipolar, Depression, High Cholesterol, Low Back Pain, Migraines, Sleep Disorder

DSS.

Stro g Fam Has -South Dakota's Foundation and ur Future

40-year-old male $28,096 Total Spend $4,544 Rx Spend, 4.7 Rx/mo, 7 chronic drug

• classes

3 ER Visits 1 IP Admits $2,399 IP spend 5 physicians Hx of Bipolar, COPD, Schizophrenia, Smoker, Substance Abuse $20,195 Rx Spend , 15.7 Rx/mo, 12 chronic drug classes 15 ER Visits 5 IP Admits, $13,863 IP spend 27 physicians Hx of Bipolar, Chron ic Pain, Low Back Pain, Musculoskeletal disorder, obesity, pre-diabetes, Schizophrenia, Sleep Disorder, Smoker and Substance Abuse.

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Health Homes

Provider Capacity

• Current number of Health Homes= 112, serving 120 locations;

54 7 designated providers

• Federally Qualified Health Centers = 23
• Indian Health Service Units = 11
• Community Mental Health Centers = 11
• Private Clinics = 67

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Recipient Participation

• 6,072 recipients in Health Homes as of 12/23/14

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CMHC IHS

10 1,104 648 293 2,055

Other

73 1,859 901 403 3,236

Clinics Total

90 3,222 1,955 805 6,072

DSS.

Stro g Fam Has -South Dakota's Foundation and ur Future 28

Health Homes

Outcome measures

• Developed by workgroup with providers
• Will be shared with CMS and used for program evaluation

purposes

• Two Sets
• Primary Care Providers
• Community Mental Health Centers

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Health Homes

Outcome measures -Primary Care Providers

• Over 30 outcome measures
• Primary goals
• Improving health of Medicaid Health Home recipients
• Providing cost-effective, high-quality care
• Transforming primary care delivery system
• Use standardized measures and tools already in use by providers

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Health Homes

Outcome measures -Primary Care Providers

• Improving health of Medicaid Health Home recipients
• Number screened for depression
• Number identified with asthma who have remained on meds
• Hemoglobin and blood pressure rates for diabetics
• Percent screened for breast cancer
• Providing cost-effective, high-quality care
• Resource utilization
• Emergency room utilization
• Hospital readmissions
• Transforming primary care delivery system
• Resource referrals
• Individual care plans
• Transfer of care plans

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Health Homes

Outcome measures -Community Mental Health Centers

• Over 40 outcome measures
• Primary goals
• Improving health of Medicaid Health Home recipients
• Providing cost-effective, high-quality care
• Transforming primary care delivery system
• Use standardized measures and tools already in use by providers

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Health Homes

Outcome measures -Community Mental Health Centers

• Improving health of Medicaid Health Home recipients
• Medication management
• Screening for co-occurring conditions
• Use of pro-active patient management
• Providing cost-effective, high-quality care
• Appropriate levels of care
• Reduction of hospitalizations
• Use of follow-up care
• Transforming primary care delivery system
• Self-management
• Care plan development
• Patient follow-up

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Assessing Quality and Effectiveness

• Outcome Measures
• Baseline data relative to clinical outcome measures being collected

from first year of the program.

• Data submission due late January for July- Dec 2014.
• Positive improvement relative to a number of health outcomes

during the first year.

• Hypertension
• Increase in individuals adequately controlling blood pressure.
• 6.9% · PCP
• 6% -CMHC
• Vascular Disease
• Improvement in LDL-C levels

5.8% · PCP

• 6.4% - CMHC

DSS"

Stro g Famllles -South Dakota's Foundation and ur Future

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Assessing Quality and Effectiveness

• Outcome Measures
• Depression Screening
• Increase in number of age appropriate screening and follow up
• 6.9% increase - age 12-17 and 6% ages 18+ PCP
• 12.6% increase- age 12-17 and 13.7% ages 18+ - CMHC
• Care Transitions
• Improved communication/notification from inpatient facility to home or other care

professional upon discharge

10.5% increase - PCP

• 20.8% increase - CMHC
• Medication Management
• Improved documentation of all current medications

.07% increase - PCP

• 8.1

% increase - CM HC

DSS4\

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Assessing Quality and Effectiveness

• Quality Assurance Reviews
• DSS RNs review medical records of Health Home recipients
• Program Cost
• Validation of PMPM payment based on actual costs

associated with core service provision

• More detailed analysis relative to costs to be developed over

the next several months to determine overall cost effectiveness

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Success Stories

• Male age 54 with diagnoses of Bipolar Disorder type I as well as
• pioid and benzodiazepine dependence in remission.
• Going to the ER almost daily when the program began working

with him in the START program (HH pilot project). Worked to get the visits decrease to just two for the remainder of the 1st year that we worked with him. ER visits continue to be minimal.

• Learned that he cannot only utilize the IMPACT staff (as he is a

part of the program), but can also seek out staff from the Recovery and Transition team when he needs additional

• support. This has been instrumental in decreasing his visits to

the ER.

• Volunteers at Avera Behavioral Health. As a volunteer, he works

with the maintenance department.

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Success Stories

• Male age 63 with diagnoses of Diabetes Mellitus and Coronary

Artery Disease, Truck driver.

• HgA

1 c 9.1 weight 280 lbs. , BP 138/87 not exercising.

• Worked on setting goals around diet and exercise.
• 3 months later exercising 4-5 times/week replace unhealthy

snacks with healthier choices and reduced portion size, quite drinking soda and increased his water intake.

• HgA

1 c is now 5.1 weight 245 lbs. and BP 110/70.

DSS4\

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Success Stories

• Female age 22 with diagnoses of Borderline Personality Disorder

and Major Depression , along with numerous physical health conditions.

• Residing as an inpatient at Avera Mc Kennan Hospital (main

hospital, not behavioral health) for most of two years following a serious car accident. (Connect with 6 day stay hospital stay reporting program).

• She was bed ridden and unable to walk on her own. She also

had a history of doing things such as re-opening wounds when she was close to discharge from the hospital as a way of prolonging her stay.

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Success Stories

• Today, she resides at a long-term care facility but is now walking

independently.

• She has stopped re-opening her wounds and her remaining

wound is almost entirely healed.

• She is next on the waiting list at a assisted living facility and

given her remarkable progress, she should be able to take another step toward becoming more independent.

DSS4\

Stro g Famllles -South Dakota's Foundation and ur Future

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Next Steps

• Increase number of Health Homes to improve geographic access
• Expand model to other payers to align collection of outcomes

measures and encourage increased provider participation

• Comparison of outcome data submission to benchmark
• Provide technical assistance to providers

DSS4\

Stro g Famllles -South Dakota's Foundation and ur Future

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Money Follows the Person

• Recommendation of the Medicaid Solutions Workgroup
• Collaborative effort with the Department of Human Services designed

to help transition Medicaid residents from long-term care institutions to home and community based services.

• Remove barriers that exist to successfully transitioning to the community
• Transition coordinators develop and facilitate community supports
• Began implementation in 2014.
• Program has received 34 referrals to date
• Of those referrals, 9 individuals were eligible and transitioned to community based

settings

• Referrals continue to be received and evaluated
• Advisory Board that includes consumers, providers, and other key stakeholders

providing input 42

Federal Regulatory Changes

• New requirements for Home and Community Based Services providers with DSS

primary impact Assisted Living

• Intent of the rule: Maximize the opportunities for participants in Home and Community

Based Services (HCBS) programs to have access to the benefits of community living.

• Allow participants to receive services in the most integrated setting.
• Compliance requirements in 7 key areas:
• dignity and respect,
• privacy and autonomy
• community integration
• facility location
• living arrangements
• physical accessibility.
• All states required to submit a Transition Plan to CMS on or before March 17, 2015.

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Federal Regulatory Changes

• States required to assess providers in 7 Key Concept areas:
• 132 Assisted Livings submitted a Provider Self-

Assessment.

• DSS performed site assessments at 131 facilities (99°/o ).
• Interviewed 159 (18°/o) of the individuals in assisted living.
• Utilized CMS's 86°/o Compliance Threshold to determine

compliance issues required to be addressed in transition plan.

• DSS will address remediation on an individual setting basis

when a concept area has 86°/o or more compliance.

• Statewide compliance and action items will be used when a

concept area is less than 86°/o as shown by either the provider, staff, or individual results.

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Federal Regulatory Changes

• Assessment results indicate South Dakota in compliance in

majority of the 7 key concept areas.

• No statewide compliance issues identified in these areas:
• Dignity and Respect
• Location
• Physical Accessibility
• Autonomy
• Individual facility remediation in some areas

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Federal Regulatory Changes

• Statewide compliance items identified in some areas
• Privacy
• Living Arrangements
• Community Integration
• DSS/DHS collaboratively working with providers for the past

several months

• Multiple opportunities for input/comment relative to the

transition plan

• Next Steps:
• Conducting regional meetings to present draft transition plan

during informal comment period

• Formal comment period begins late January 2015
• Regional meetings planned in February for final review of plan

before submission to CMS in March

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Behavioral Health

• Behavioral Health Workgroup established in 2011 by

Governor Daugaard after reorganization of behavioral health services

• Created to guide the long-term vision of the behavioral

health system

For more information1 visit http://dss.sd.gov/behavioral hea lthservices/index.asp

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Behavioral Health

Progress on Workgroup Recommendations

• Expanded evidence-based assertive community treatment

services for individuals with serious mental illness

• New programs created in Pierre and Aberdeen , in addition to current

programs in Sioux Falls, Rapid City, Yankton , and Aberdeen

• Implemented evidence-based substance abuse and criminal

thinking services for individuals involved with the criminal justice system

• Substance abuse services - 13 providers - covering all judicial circuits
• In FY14, 271 referrals
• Criminal thinking services - 3 providers - covering all judicial circuits
• In FY1 4, 196 referrals
• Rural pilot - 2 providers - 1st, 5th, and 61

h judicial circuits

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Behavioral Health

Progress on Workgroup Recommendations

• Implementing mental health and supported housing services for

young adults transitioning to the community from of out-of-home placements

• Created a geriatric admission unit at HSC
• Created a clinical review process to provide psychiatric and

nursing review/consultation to nursing facilities

• Established a specialized nursing home in Irene, South Dakota

with the capacity to serve 11 individuals with challenging behaviors

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Behavioral Health

Progress on Workgroup Recommendations

• Collaborated with the Attorney General's Office to utilize funding

from Janssen Pharmaceutical settlement

• Educational opportunities for individuals with mental illness and their family

members

• Crisis intervention training for law enforcement officers
• Mental Health First Aid training for community members
• Suicide intervention training
• Questions?

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