KEPRO Oregon Health Plan Care Coordination Program John R. - - PowerPoint PPT Presentation
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
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.
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The KEPRO Oregon Team
Direct Service Staff
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).
safe and timely way, and collaborate with physicians and other health care providers to establish, implement and maintain quality patient care and services.
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KEPRO Services
members of Oregon Health Plan with Medicaid and Dual-Eligible (Medicaid and Medicare). 4
and Qualified Agent for behavioral health services for Medicaid members under the 1915i Program.
with an average of 120,000 members.
KEPRO has been serving with the Oregon Health Authority since 2009.
Oregon Medicaid by Population
5 Managed Care Members: CCO Managed
93,000+ Fee-for Service (FFS) members
Line and care coordination services for the populations above.
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:
support systems in order to guide them to improved health.
better lifestyle choices.
and more.
such things as transportation, paying household utilities, or locating a doctor or a specialist.
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KEPRO Integration of Services
What is the optimal setting for Joe?
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Meet Joe
Joe is a 78 years-old member who has struggled with diabetes for
recently fell and broke his hip. Joe is served by KEPRO, and he receives care from APD and other agencies.
KEPRO: Clinical Assessment APD Case Mgr: ADLs ITU
. Alerted by census information . Identified as high-risk through the Peculator System assessment . Provide care coordination . Provide social services . Secure primary care services . Implement medication management . Leverage C3 System medical history and claims data . Review referrals from case workers . Coordinate discharge planning . Coordinate transitions of care settings . Assess care provided by ITU . Coordinate with KEPRO resources . Jointly develop a plan of care . Coordination with Native American Liaison . Complete assessments for services . Refer member to KEPRO . Authorize services for home care . Authorize facility care . Approve food stamps . Utilize Access Oregon System . Authorize contract nurse activity
State Contracted Nurses
. Provide in-home presence . Provide face-to-face interactions with member
Jeffrey McWilliams, MD, Medical Director
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Care Coordination Strategies
STRATEGY HEADLINE In-Home Medication Reconciliation Top reason for readmission is improper use of medications. Community-Based RNs visit members in home to ensure appropriate medications and other care. Referrals to APD Case Manager Services Our RNs have the capability to refer members to Case Managers at APD so that they can receive services based on APD Service Priority Level (1-13). Transitions of Care Community-based RNs coordinate care with discharge planners and providers to facilitate
Fall Prevention All Community-based RNs are trained to do a full fall prevention check list with members to minimize risks for patient falls. Integration of APD Assessment Data Oregon Access is the APD system that tracks member services offered through the State. KEPRO maximizes coordination through our C3 Care Management System. Nursing Home Diversion Activities Our goal is to provide appropriate services and minimize costs when working with a member to leave a nursing facility or when transitioning a member to a more optimum facility. Serious and Persistent Mental Illness Behavioral health challenges are persistent in this population. Medical care and behavioral health care are closely coordinated for diseases and suicidal tendencies Diagnosis-Specific Care Fundamental disease-specific care management (for example, Diabetes) is a foundation upon which the program is built. 9
General Assessments
Pediatrics
Condition Specific Assessments
KEPRO Assessments
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Informational Mailings
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Educational Sheets
Multiple languages and formats available are provided to members.
Our Members
One of our Community-based RNs, was working with a member when it became evident that the member and her seven-year-
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.
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Kevin Minor, LCSW, Behavioral Health Manager
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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):
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These services are provided to
accessing behavioral health services.
been determined to no longer need that setting in order to receive appropriate services and supports.
Behavioral Health
Conflict-Free Case Management
KEPRO coordinates care for identified Medicaid recipients who are enrolled FFS and who present as needing assistance to access appropriate behavioral health services. For each member in this population, KEPRO conducts a face-to-face evaluation and prepares a person-centered services and support plan for use by providers. 15
Oregon State Hospital (OSH)
KEPRO plans and coordinates the timely transition of individuals residing in the OSH who have been determined to no longer require hospital level of care and who have been placed on the Ready to Transition (RTT) list. For each person transitioned from OSH, a hospital-to-community transition plan, in the form of a written person- centered services and supports plan is developed by KEPRO. Each plan-of-care meets the defined standards for assessment and person-centered planning. The plan of care is provided to the person and the contracted community entity responsible for the coordination of care for the person prior to the transition allowing the appropriate time necessary to implement the plan.
Licensed Treatment Programs
KEPRO plans and coordinates the transition of individuals residing in a level of care funded by the OHA who have been determined as able to receive appropriate services and support in a more integrated community setting. For each person transitioned from a licensed level of care to a more integrated community setting (licensed or non- licensed), a community transition plan, in the form of a written person-centered services and support plan, is developed by KEPRO. Each plan-of-care meets the defined standards for assessment and person-centered planning.
KEPRO Behavioral Health
1915i Eligibility Determinations
criteria set forth under State’s Plan Needs-Based Home and Community-Based Services (HCBS) Eligibility Criteria.
clinical information submitted by a staff employed by the Community Mental Health Program (CMHP) or their subcontractor to make the 1915i eligibility determination.
Care Utilization System (LOCUS), Level of Service Inventory (LSI) or other relevant documentation. 16
Medical Appropriateness Reviews
submitted and the documentation meets the requirements defined in Oregon Administrative Rules (OAR).
condition.
Treatment Episode Monitoring
applicable OAR and that the services meet criteria for quality and medical appropriateness. KEPRO completes this through onsite face-to-face meetings, document review or data analysis.
Thank you for your time today. KEPRO looks forward to continuing and enhancing
Questions & Answers.
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