KEPRO Oregon Health Plan Care Coordination Program
John R. DiPalma, Executive Director Mission In partnership with the Oregon Health Authority (OHA) and the Oregon Department of Human Services, KEPRO strives to enhance the lives of those we serve by achieving the Triple Aim of better health, better health care and lower costs for the state of Oregon. At KEPRO, we focus on providing intelligent value in everything we do to make a positive difference in the lives of the people we serve. 2
The KEPRO Oregon Team • John R. DiPalma, Executive Director • Jeffrey McWilliams, MD, Medical Director, Board Certified Oncologist/Hematologist • Lauretta Young, MD, Psychiatrist • Maggie Klein, MS, MSN, JD, Clinical Operations Director • Kevin Minor, LCSW, Behavioral Health Services Manager • Heidi Leonard, Operations Manager • Sheri Kellams, RN, Clinical Care Supervisor • Cortnee Riddle, LPN, Care Coordinator Supervisor Direct Service Staff • Our Clinical Staff assist members by phone and meet with members face-to-face in the field. Our clinical staff provide health assessments, medication reconciliation, connect members to a medical home, coordinate with community resources and close care gaps in medical care. Our clinical staff include Registered Nurses (RN), Licensed Practical Nurses (LPN) and Licensed Clinical Social Workers (LCSW). • Our Care Coordinators help members navigate the health care system to get the care they need in a safe and timely way, and collaborate with physicians and other health care providers to establish, implement and maintain quality patient care and services. 3
KEPRO Services KEPRO has been serving with the Oregon Health Authority since 2009. • In July 2016, KEPRO became the State’s Independent and Qualified Agent for behavioral health services for Medicaid members under the 1915i Program. We provide Care Coordination for Fee-for-Service • members of Oregon Health Plan with Medicaid and Dual-Eligible (Medicaid and Medicare). • Out of the 1.3MM in Medicaid members, KEPRO works with an average of 120,000 members. 4
Oregon Medicaid by Population 93,000+ Fee-for Service (FFS) members Managed Care Members: CCO Managed • KEPRO has contracted with the State of Oregon to provide a 24-hour Nurse Advice and Triage Line and care coordination services for the populations above. • In total, approximately 120,000 members benefit from KEPRO’s services. 5
KEPRO Services Outreach and Activities The OHPCC Program conducts member outreach through various means and approaches. The outreach efforts include telephone calls, welcome packets, newsletters, disease-specific mailings, preventive care reminders, action plans and the Nurse Advice and Triage Line. OHPCC Program staff assist members through the following activities: Outreach to members to complete a thorough assessment of their health, living situation and • support systems in order to guide them to improved health. Provide helpful and effective educational, resource and referral information to help members make • better lifestyle choices. Provide a Plan of Care consistent with their provider’s care. • Work with members on medication compliance, exercise, diet, scheduling appointments, education • and more. Provide resource assistance to members in need of community or state assistance programs for • such things as transportation, paying household utilities, or locating a doctor or a specialist. 6
KEPRO Integration of Services Meet Joe What is the optimal setting for Joe? Joe is a 78 years-old member who has struggled with diabetes for Hospital Residential Living • • over 21 years. Unfortunately, Joe Rehabilitation Group Home • • recently fell and broke his hip. Home Other? • • Joe is served by KEPRO, and he Assisted Living • receives care from APD and other agencies. KEPRO: Clinical Assessment ITU APD Case Mgr: ADLs . Alerted by census information . Assess care provided by ITU . Complete assessments for services . Identified as high-risk through the Peculator . Coordinate with KEPRO resources . Refer member to KEPRO System assessment . Jointly develop a plan of care . Authorize services for home care . Provide care coordination . Coordination with Native American . Authorize facility care . Provide social services Liaison . Approve food stamps . Secure primary care services . Utilize Access Oregon System . Implement medication management . Authorize contract nurse activity . Leverage C3 System medical history State Contracted Nurses and claims data . Review referrals from case workers . Provide in-home presence . Coordinate discharge planning . Provide face-to-face interactions with member . Coordinate transitions of care settings 7
Jeffrey McWilliams, MD, Medical Director 8
Care Coordination Strategies STRATEGY HEADLINE Top reason for readmission is improper use of medications. Community-Based RNs visit In-Home Medication members in home to ensure appropriate medications and other care. Reconciliation Our RNs have the capability to refer members to Case Managers at APD so that they can Referrals to APD Case receive services based on APD Service Priority Level (1-13). Manager Services Community-based RNs coordinate care with discharge planners and providers to facilitate Transitions of Care optimum placement. All Community-based RNs are trained to do a full fall prevention check list with members to Fall Prevention minimize risks for patient falls. Oregon Access is the APD system that tracks member services offered through the State. Integration of APD KEPRO maximizes coordination through our C3 Care Management System. Assessment Data Our goal is to provide appropriate services and minimize costs when working with a member Nursing Home to leave a nursing facility or when transitioning a member to a more optimum facility. Diversion Activities Behavioral health challenges are persistent in this population. Medical care and behavioral Serious and Persistent health care are closely coordinated for diseases and suicidal tendencies Mental Illness Fundamental disease-specific care management (for example, Diabetes) is a foundation upon Diagnosis-Specific Care which the program is built. 9
KEPRO Assessments General Assessments Condition Specific Assessments Medication Reconciliation Tobacco Cessation • • Diabetes Transition Of Care • • DM • Dual Needs Assessment • Substance Abuse • Enrollment Assessment for Social Needs • Anxiety • Behavior Risk Assessment CAD • • Cancer Enrollment Assessment for Social Needs • • COPD Pediatrics • Heart Failure • Behavior Risk Assessment, Pediatrics • HTN • Medical Adherence • Stress Management • 10
Informational Mailings Multiple languages and formats available are provided to members. • Welcome Packet • Unable-to-Reach Postcards • Staywell, Krames • Action Plans • Disease/Condition-Specific Educational Sheets • Quarterly Educational Newsletters 11
Our Members One of our Community-based RNs, was working with a member when it became evident that the member and her seven-year- old son were living out of their car. Our Community-based RN determined that the son was suffering from a condition requiring surgery. In less than one week, our Community-based RN scheduled the surgery and coordinated the follow-up care for the mother. She worked with a local agency to provide housing services for the family. The surgery was successful and the young boy was able to recover in the newly established housing. 12
Kevin Minor, LCSW, Behavioral Health Manager 13
KEPRO Behavioral Health Independent and Qualified Agent Services KEPRO provides the following Independent and Qualified Agent (IQA) Services in Oregon (as of July 1, 2016): • Conflict-Free Case Management • 1915i Eligibility Determinations • Medical Appropriateness Reviews • Treatment Episode Monitoring These services are provided to • Medicaid-eligible individuals in the state of Oregon who are fee-for-service (FFS) and need assistance accessing behavioral health services. • Individuals residing at Oregon State Hospital who have been determined as ready to transition (RTT). • FFS Medicaid members who are currently residing in an OHA-funded licensed level of care and have been determined to no longer need that setting in order to receive appropriate services and supports. 14
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