Dual Eligible Planning Grant Statewide Partners Meeting February 21, - - PowerPoint PPT Presentation

Dual Eligible Planning Grant

Statewide Partner’s Meeting February 21, 2012

DRAFT

Demonstration Design

• Fully Dual Eligible Adults (>21 yrs.) = 222,151
• Statewide, all 100 Counties
• Managed fee for service model building on current medical home

infrastructure

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Beneficiary Goals

Function Based Resource Allocation Flexible Use of Public Funds for Supports Independent Assessment of Need

DUAL ELIGIBLE STRATEGIC FRAMEWORK

Beneficiary Centered Medical Homes

Use of Actionable Data

Natural Supports and Community Resources

Provider Capacity Incentives

DRAFT

Quality of Life & Self- Management Support Primary Care, Preventive Care & Pharmacy Assistance Independent Living Skills/ Habilitation Recovery & Behavioral Health Support Acute Care & Rehabilitation Daily Living Supports Palliative Care

Beneficiary Goals

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Natural Supports and Community Resources

Dual Eligible Model Enhancements

• Engage beneficiaries &

community stakeholders to guide model

• Improve access to training and

education for beneficiaries, family caregivers & providers

• Develop broader community

dialogue about advance directives & palliative care

• ptions
• Support for evidence-

based best practice programs

* Family * Faith-Based Supports * Friends * Accountable Care Organizations

* Emerging Initiatives

Natural Supports and Community Resources

* Community and Social Supports

DRAFT

Enhanced Quality

Medicare 646:

• Quality measures
• Lessons learned

Dual Model Strategies

• Quality indicators for

medical homes, all settings

• Provider tiers with

explicit capacity and performance standards Dual Model Goals

• Increased beneficiary

satisfaction

• Improved health
• utcomes
• Shared savings

DRAFT

Beneficiary Centered Medical Home

* Screening and Assessment * Self Management Education * Evidence Based Practices * Team Based Care Management * Pharmacy Management * Behavioral Health Integration * Clinical Information Systems * Transition Supports

Dual Eligible Model Enhancements

• Medical homes for duals in all

settings

• Medicare 646 demonstration

experience

• Explicit expectations for provider

quality improvements

• Greater provider capacity via

incentives- ex: treatment in place

• 24/7 call response capacity
• New communication protocols, tools
• Information sharing resources

enhanced

• Palliative Care Capacity

Beneficiary Centered Medical Home

* Risk Stratification * Primary Care Physicians

* Preventive care

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HIE ADRC Beneficiary Information ED/Hospital E- Prescribing Assessment Data

Information Access

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FUNCTIONAL NEEDS MATRIX

PHYSICAL HEALTH IMPAIRMENT MENTAL HEALTH/COGNITIVE/EMOTIONAL IMPAIRMENT QUADRANT 1 QUADRANT II

INTACT MILD MODERATE SEVERE INTACT MILD MODERATE REHAB

• MED. CONDITIONS+/-
• OPPO. BEHAVIORS

CLINICALLY COMPLEX SPECIALIZED CARE

QUADRANT III QUADRANT IV

Home and Community Based Services Dual Eligible Model Enhancements

• Flexible use of public

funds

• Coordinate with

developing Community Resource Connections such as ADRCs

• Grow peer support

capacity and recovery

• riented behavioral

health supports

• Maximize use of

technology

* Current Medicaid waiver programs and other in home care services * Money Follows the Person,

• ther transition programs

* PACE * Adult Day programs

Home and Community Based Services

* Respite and other caregiver support * Rural Primary Care Access * Assistive devices * Other HCB programs

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Tier 2 Tier 1

Tier 3 Tier 4

Tier 5

Medical Home for Nursing Home Residents

Tier 1 Standards * Medication review * Licensed Medical Director and individual attending physicians *Attending physicians for residents (intermittent/week) * Advanced directives in place * Access to registered dietitian

Tier 2 Standards ( +1) * Medication reconciliation (Med. Rec.) by CCNC * Explicit attention to psychotropic and anticoagulant/ anti-platelet drugs * Attending physicians review and act on med. rec. recommendations Legal guardian/DMPA identification and acquisition policy in place * Standard access to provider portal information/reports Tier 3 (+1,2) Standards * Physician presence on site fixed days/times of the week (1-2 days) * Facility encourages a reduced # of physicians attending residents * Advance directives (reviewed every 6 months) * All transitions have clear communication prior to leaving facility (transition policy in place with transfer form, name and number of single contact) * Oral health care for residents Tier 4 Standards ( +1,2,3) * 24/7 Call system with trained LTC providers * Regular on-site schedule 2-3 days per week * Embedded MD/NP * Patient wishes/care goals evident in medical records * Medication review with risk-benefit assessment * Root cause analysis of unplanned ED/ hospital admissions * Clearly established performance standards * Enhanced oral health care

Tier 5 Standards ( +1,2,3,4) * 24/7 Call system with consultation * Embedded MD serves as Medical Director * First page of chart to display patient wishes *As appropriate, palliative care goals- prominent and current with evidence

• f discussion with patient/family/

designated caregiver * Periodic review of med list; e- prescribing, e-reconciliation

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Tier 1

Tier 2 Tier 3

* All residents enrolled in medical homes with their PCP * Patient care goals documented * Established relationship with LME for residents with behavioral health needs * Resident medication review & reconciliation, care management, evidence-based health, wellness and self-management education facilitated by Network * Electronic resident assessment * Advance directives discussions documented in resident records * 24/7 call support to reduce unnecessary emergency department visits/ambulance calls * Facility has established relationship with 24/7 call practice * Electronic resident assessment records accessible to PCPs * Communication protocols for hospital and ED transitions * Facility encourages residents toward fewer PCPs * Treatment in Place * Protocols in place and regularly updated to identify and respond to early warning signs to avoid crises * Advance directives for residents with behavior health conditions * Prepared for family/resident palliative care and hospice care plan implementation * E-prescribing Other incentives for achieving Tier 3: * Potential regulatory relief ** Reductions in unnecessary hospital admissions result in potential shared savings

Medical Home for Adult Care Home Residents

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Potential Shared Savings

• Strategic Priorities will be based on Medicare data analysis
• Multiple elements for anticipated savings, most notable areas,

– Medication therapy management – 24/7 call coverage to reduce unnecessary emergency department use – Increase access to primary care supports to reduce avoidable hospital admissions

DRAFT

Dualfuture@n3cn.org

http://www.communitycarenc.org/emerging- initiatives/dual-eligible-initiative/