Info about presentation • The Holy Grail: Integrating Care through Regional & Statewide CBO Networks for Contracting

with Healthcare

• Objectives:

• Participants will learn about two models for building regional networks to contract with healthcare entities – a brokerage model and a lead agency model

• Participants will be able to articulate 5 reasons why joining a CBO network can be advantageous

• Participants will know five challenge to building a network

• Participants will identify three key elements for success in contracting with healthcare entities

•

• For over a decade, San Diego Aging & Independence Services and Partners in Care Foundation, one a public AAA and the other a private nonprofit, have pursued the holy grail of person-centered integration of healthcare and social services. Each formed a network of CBOs to provide a full menu of high quality services across a broad geography as opportunities spurred by the ACA began to develop. Between the two organizations, there are more than 20 contracts with over 15 healthcare payers. Some of these contracts have been extremely successful and others have sputtered along with low volume. This workshop will identify the advantages and challenges of forming regional networks and successes and challenges in contracting with healthcare payers. These lessons are crucial if AAAs and other CBOs are to achieve the vision of sustainability and quantum leaps in creating positive health outcomes for aging and disabled people across the nation.

The Holy Grail: Integrating Care through Regional &

Statewide CBO Networks for Contracting with Healthcare

Kristen Smith, Aging Program Administrator Aging & Independence Services

County of San Diego Health and Human Services Agency

Sandy Atkins, Vice President Partners in Care Foundation

2017 n4a Conference

Thanks to our funders for helping us be trailblazers

John A. Hartford Foundation Archstone Foundation

SCAN Foundation Administration for Community Living

Parsons Foundation Ahmanson Foundation

n4a

Health Care + Social Services = Better Health, Lower Costs

• Address social determinants of health − Personal choices in everyday life − Isolation, family structure/issues, caregiver needs − Environment – home safety, neighborhood − Economics – affordability, access

• Social Service Agencies Have Advantages − Lower cost staff & infrastructure − Time to probe, trust, different perceived authority − Cultural/linguistic competence − Local knowledge and relationships − High impact evidence-based programs

A Competitive Opportunity/Risk

Managed care plans have 3 options for HCBS:

1. Use their own staff (nurse case managers, for example) for care

coordination or other services (usually telephonic)

2. Subcontract with large for-profits that can cover significant

geographies (often national)

• Disease management

• Behavioral health

• Homecare

3. Subcontract with CBOs who have efficient operations, experience

with home visits, local knowledge and cultural competency in their

regions.

• Even if it’s “just” for eyes & ears in the home

HEALTH AND HUMAN SERVICES AGENCY

AGING & INDEPENDENCE SERVICES (AIS)

40 Years of Experience

In-Home Supportive Services

Case Management:

MSSP, Linkages

SOAR, SD-VISA

Live Well Care Connections

Adult Protective Services

Call Center

Diabetes Prevention

Diabetes Self-Management

Ombudsman

Volunteerism

Feeling Fit Club Caregiver Respite

Chronic Disease

Self-Management

Fall Prevention

6

Outreach & Education

Intergenerational

PA/PG/PC

Alzheimer’s

<<<<Independence Dependence>>>>

HEALTH PROMOTION PROGRAMS

7

Tai Chi: Moving for Better Balance

Feeling Fit Club

Diabetes Prevention Program

Diabetes Self-Management

Chronic Disease Self-Management

SAN DIEGO CARE TRANSITIONS PARTNERSHIP

COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP)

Jan 2013 – March 2017

4 health systems/13 hospitals

& AIS

Over 57,000 patients

• Coleman Care

Transitions Intervention

(RN)

• Care Enhancement (SW)

8

Readmissions

SAN DIEGO COORDINATED CARE INITIATIVE

Successful integration:

Care Coordination Unit

Program Implementation Guide

Informal case consults and ICT’s

Data sharing

Infrastructure for ongoing communication (CCI Advisory

Committee, AIS-CCI Health Plans Committee)

550 MSSP Clients

27,000 IHSS

Clients

14,000+ CMC

Members

9

LWCC PARTNERS

Funder/Partner:

Palomar

Partners in Care

Foundation

(for Blue Shield of

California)

Alzheimer’s ACL Grant

More TBD

Live Well Care Connections

C O M I N G S O O N

10

LIVE WELL CARE CONNECTIONS AND OTHER CASE MANAGEMENT PROGRAMS:

Care Plan:

• Meals; transport; chores; grab bars; home care; respite; health promotion

• Via:

• Informal support & self-management

• Gov’t & Community

• Purchased Services 11

Outcomes:

•Meet client goals •Reduce caregiver burden •Improve stability in home

Assess:

• Physical health, ADL’s, IADL’s

• Fall risk, Medications

• Nutrition Risk

• Mental/Cognitive/Social

• Home Environment

• Life planning, financial

• Caregiver needs

• Client Priorities & Goals

PAH NETWORK MEMBER

12

OUR SOCIAL WORKERS’ EXPERIENCE:

Technology & Documentation are KEY

Deadlines - super important

Clients: more family support, knowledgeable, higher income. Appreciate education on resources.

Clients expecting our call

PAH NETWORK MEMBER

13

HEALTH PROMOTION EXPERIENCE:

Ensure workshops are in “Hotspots”

10 workshop participants

1 or 2 PAH/BSC members

Supplements funding – couldn’t do by itself yet

RATE DEVELOPMENT

14

Time per task

• Time per Task

Case Load

• Case Load

Salaries, Benefits, Overhead

• Salaries, Benefits, Overhead

Full Cost Recovery BUT

no profit!

• Full Cost Recovery BUT no profit!

Finance Office Approval

• Finance Office Approval

CONTRACT REVIEW

15

Authority from Governing BOS

• Governing Board of Supervisors

Privacy

• Ethics/compliance

IT Security

• Privacy

HR – Risk

• HR – Risk/Insurance, Background

Counsel

• IT Security

Signature process!

• Counsel stamp of approval

Signature

•Signature!!!!

GOAL, SCORING & BENEFITS OF ACCREDITATION CONT.

NCQA CM LTSS Standards:

LTSS 1: Program Description, 5.0 points

LTSS 2: Assessment Process, 20.0 points

LTSS 3: Person-Centered Care Planning & Monitoring, 25.0 points

LTSS 4: Care Transitions 20.0 points

LTSS 5: Measurement and Quality Improvement, 15.0 points

LTSS 6: Staffing, Training and Verification, 15.0 points

LTSS 7: Rights and Responsibilities, 5.0 points

LTSS 8: Delegation of LTSS (Only scored if applicable)

16

NCQA ACCREDITATION

3 YEAR CASE MANAGEMENT LTSS ACCREDITATION

Scoring thresholds associated with each status are shown in the table:

ACCREDITATION STATUS STANDARDS SCORE

Accredited- 3 years 85-100

Accredited- 2 years 70-84.99

Denied Below 70

NCQA Case Management LTSS Final Standards

8 Standards

37 Elements

170 Factors

17

Building the future together

Networks of CBOs will

enable all boats to rise together and

give us scale to compete successfully

in post-ACA markets

Theory behind the Network

• IF CBOs join together to present a unified, multiregional

contracting entity to large healthcare organizations

• AND they can meet the quality, volume, confidentiality,

geographic coverage and information needs of healthcare

• AND they can demonstrate their value: Triple Aim

• AND they are competitively priced

• THEN they will win contracts with healthcare entities and

perform well

Partners at Home Network for an Integrated Community Care System

Care & Service Coordination

Comprehensive Assessments

HomeMeds/Med Reconciliation

Evidence-based Self-Management

Workshops

LTSS: Meals, transportation, home

mods, etc.

Caregiver Education & Support/Respite

Network Office

One Call Does it All!

Partners at Home Growing Footprint Expand Network footprint to cover added markets to meet our customer’s needs

Network as of June 2016

Active Network Counties Alameda

Butte

Contra Costa

El Dorado

Fresno

Humboldt

Imperial

Kings

Kern

Los Angeles

Madera

Marin

Mendocino

Merced

Monterey

Nevada

Orange

Placer

Riverside

Sacramento

San Bernardino

San Diego

San Francisco

San Mateo

San Joaquin

San Luis Obispo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Solano

Sonoma

Stanislaus

Tulare

Ventura

Yolo

Part of the National Aging and Disability Business Center Series – a collaboration of n4a and ASA.

How We Built PAH Network 1. Partners in Care Foundation started with statewide collaborative for evidence-based

programs in partnership with California Depts. of Aging & Public Health

2. San Diego AIS and Partners developed collaboration among Community-based

Care Transitions Program (CCTP) providers to avoid duplication and inability to bill

CMS – support group re: CMS & share best practices/challenges

3. Subcontract with each other for patients whose homes are in another member’s

geographic area

4. Seek contracts for other payers/hospitals (as Care Transitions SoCal)

5. Build business capacity through ACL learning collaborative

6. Expand to include other geographies & services to create comprehensive,

statewide, community care system

7. Et Voilà! Partners at Home!

Why Join a Network? • Large Healthcare Entities want one-stop shop • Contracting is expensive

− Legal fees – one contract $40,000+

• Contracting is time consuming – multiple meetings every week over 9 months – ~2,000 hours of senior/ executive team time for one contract

− Build the relationship – materials, business case − Negotiate the contract – pricing, terms, requirements − Roll out the program

• Develop workflows • Policies & procedures • Hire & train staff

− Reporting & evaluation

More Reasons to Belong Competition – Large national companies like APS promise

efficient service, unified IT, analytics, quality assurance

Medical Loss Ratio – Billing Health Plans must spend 85% on clinical care & quality

No more pilots under administrative budget To be clinical, you need license &/or accreditation

Accreditation is costly ($33,000+) Requires huge effort…better through a single entity. May be required for contracting with health plans other than

Medicaid, especially Medicare License: Shared cost for licensed supervision Medicare Provider # Difficult

Diverse populations have diverse needs –Require a broad range of skills and specialties including: Behavioral health and some of the disability specialties Substance abuse/addiction issues

Network Lead Agency Functions 1: Meet Health Plan Due Diligence Requirements

• Credential network members to assure compliance with contract terms

− HIPAA/HITECH security

− IT Systems for data exchange

− Insurance

− Staff – drug testing, background check, TB test, etc.

− License/certification/accreditation

Network Lead Agency Functions 2: Quality Assurance

• Support accreditation through business office

• Ensure consistent delivery of service

• Fidelity to evidence-based models

• Performance data

• Supervision by licensed personnel (e.g., LCSW, RD, RN)

• R & D – evaluation

Network Lead Agency Functions 3: Business Office

• Shared sales & marketing

• Negotiate and hold contracts

• Billing & service authorization

• Maintain IT infrastructure

• Legal support

• Call center/communications systems

• Policies/procedures – HIPAA/HITECH

Network Development Lessons Learned

• You don’t need to include everyone − Excellence, entrepreneurial/risk-takers

• Stay connected to members

• It’s awkward to monitor your friends’ work

• Be transparent about expected volume

• Be transparent regarding fees (share the pricing model)

• Survey how it’s going for everyone

• Share impact & outcomes

• Fair is not synonymous with same/equal

Partners at Home (A California Network)

• Trust Paved Our Way Forward

• Shared vision – Our time is now!

• Continued Buy-in as Network Developed

• Experience Together Moves the Stick Forward

• Earned Health Plan Contract Renewal!

Building the Business Case

Achieving Healthcare Contracts

Building Success with EBPs

• Two service lines based on EBPs: − Self-management – Stanford programs

− Home visits – HomeMeds, CTI, Bridge

• Blue Shield of California example − Contract for both service lines

− All insurance lines of business – from commercial/employer to Medicare Advantage to new Exchange

• Beginning to spread to other plans, etc.

Identifying Outcomes of Interest

• Reach members who need to improve health behaviors, are non-adherent, or have complex social needs

• Meet members’ community support needs

• Qualify members for benefits & programs

• Avoid adverse drug effects

• Improve medication adherence

• Improve self-care & self-management

• Improve Star ratings, HEDIS, meet NCQA CM standards

• Reduce inappropriate utilization

− ED, Hospital, SNF/Rehab • Optimize physician

performance under MACRA • Improve member satisfaction • Improve member retention

Our Contracts • Care Transitions Choices (in-home coaching or telephonic Bridge):

– Blue Shield, UCLA, Molina

• HomeMedsPlus – Assess, HomeMeds+30/60/90 days of care coordination:

– UCLA Health System, HealthCare Partners, Blue Shield, Health Net,

AppleCare

• Evidence-based self-management programs

– Blue Shield (contact info for 50,000+; we engage & enroll)

• LTSS – Waiver continuation for duals

– L.A. County Medicaid Health Plans (L.A. Care, Molina, Health Net, etc.)

• Assessment: HRAs & Adult Day Health eligibility determination

– Health Net, Care1st, L.A. Care, Centene

Winning Contracts Isn’t Enough

Referrals

Acceptance

Completion

Healthcare

Changes

• IT supports

targeting/referral

• Programming to

support data

exchange

• Champions at all

levels

• Workflow changes

• Patient/member

motivation

• Share outcomes

data

• Respect CBO

expertise

CBO Changes:

• Better IT systems

• Better IT security

• More insurance

• Accreditation

• Provider #

• Motivate health

plan CMs to refer

& work with us

• Workflow

• Understand health

plan regulations

• Motivate patients

& participants

• Address barriers

for patients

Volume is a prerequisite for sustainability

18

CCTP avoided 1,900 readmits Care Transitions: Dr. Eric Coleman’s Coaching & Rush University Bridge Models

Best in CA

Source: HSAG, CA QIO, November 2016

21.1% 20.2% 20.7%

15.4% 14.4%

12.5%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Westside (3 Hospitals) Glendale (3 Hospitals) Kern (5 Hospitals)

Rea

dm

it R

ate

Results by CCTP Site

Readmit Pre Readmit Post

27% 2 29%

40%2

2Source: CMS Quarterly

Monitoring Report Released

December 15, 2016.

*Program to Date through Jul 2016

1 Baseline (Pre): All-Cause, All-Condition, Medicare FFS: Westside & Glendale = Jan – Dec 2012; Kern = Apr 2012-Mar 2013 2 CCTP (Post): Medicare High-Risk FFS Population, Readmission Rate to Date (Westside= May 2013 – Jul 2016; Glendale = May 2013-Mar 2016; Kern = Nov 2013 – Jul 2016

N=6,745 N=13,050 N=9,463

High-value targeted home visit Jo

int

Rep

lace

men

t ER

/Fal

l • Environmental assessment

• Medication safety review

• Exercise

• Transportation to appointments

• ADL assistance

• Fall prevention education

Old

er A

du

lt P

ost

-Acu

te • Med safety review

• Med adherence

• Self-care education

• Diet-compliant meals

• Transportation to appointments

• Depression & anxiety screen

Hig

h R

isk

for

Rea

dm

issi

on

• Coleman model coaching

• Med review

• Med adherence support

• Follow-up appointments

• Coaching for self-management

• Social services, benefits, meals, transportation

SAN DIEGO COUNTY’S EXPERIENCE IN THE

“NEW LANDSCAPE”

Kristen D Smith, MPH

Aging Program Administrator

Aging & Independence Services

County of San Diego Health and Human Services

1/11/2017 37

AGING & INDEPENDENCE SERVICES

40 Years of Experience

In-Home Supportive Services

Case Management:

MSSP, Linkages

SOAR, SD-VISA

Live Well Care Connections

APS

Call Center

Diabetes Prevention

Diabetes Self-Management

Ombudsman

Volunteerism

Alzheimer’s

Caregiver Respite

Chronic Disease

Self-Management

Fall Prevention

AIS

38

Outreach & Education

Intergenerational

PA/PG/PC

HEALTH PROMOTION PROGRAMS

39

Tai Chi: Moving for Better Balance

Feeling Fit Club

Diabetes Prevention Program

Diabetes Self-Management

Chronic Disease Self-Management

SAN DIEGO CARE TRANSITIONS PARTNERSHIP

COMMUNITY-BASED CARE TRANSITIONS PROGRAM (CCTP)

January 2013 – March 2017

4 health systems and AIS

Over 56,000 patients

• Coleman Care

Transitions Intervention

• Care Enhancement

40

0%

10%

20%

30%

40%

39.8%

10.0%

30-Day Readmission Rate – High Risk Medicare

2012 (Baseline) 2/13-7/16 (CCTP Completers)

LWCC PARTNERS

Funder/Partner:

Palomar

Partners in Care

Foundation

(for Blue Shield of

California)

Alzheimer’s ACL Grant

More TBD

Live Well Care Connections

C O M I N G S O O N

41

PAH NETWORK MEMBER

42

OUR SOCIAL WORKERS’ EXPERIENCE:

Technology & Documentation are KEY

Deadlines - super important

Clients: more family support, knowledgeable, higher income. Appreciate education on resources.

Clients expecting our call

PAH NETWORK MEMBER

43

HEALTH PROMOTION EXPERIENCE:

Ensure workshops are in “Hotspots”

10 workshop participants

1 or 2 PAH/BSC members

Supplements funding – couldn’t do by itself yet

RATE DEVELOPMENT

44

Time per task

• Time per Task

Case Load

• Case Load

Salaries, Benefits, Overhead

• Salaries, Benefits, Overhead

Full Cost Recovery BUT

no profit!

• Full Cost Recovery BUT no profit!

Finance Office Approval

• Finance Office Approval

CONTRACT REVIEW

45

Authority from Governing BOS

• Governing Board of Supervisors

Privacy

• Ethics/compliance

IT Security

• Privacy

HR – Risk

• HR – Risk/Insurance, Background

Counsel

• IT Security

Signature process!

• Counsel stamp of approval

Signature

•Signature!!!!

Buy vs. Build: Why Partner?

• Community: A new specialty for SDOH

• System of Care vs. Social Work Staff

• Broad geographic coverage

• Diversity in language, culture and skills

• Efficiency – unpredictable spread of need

• Quality – NCQA accreditation for complex case management; HEDIS & Medicare Stars

Future Directions/Needs

• Volume building with nurse case managers

• Make social services data points & systems part of meaningful use successor

• Billing codes

• Provider status

• Comprehensive IT system

• HIPAA reform

• Mandatory HIE

• Bar code standardization for pharmacies

• NCQA LTSS Accreditation (@ CBO price)

National Movement to Support CBOs

• Admin for Community Living

• National Assn. AAAs

• American Society on Aging

• John A. Hartford Foundation

• SCAN Foundation

• Nat’l Assn States United for Aging

& Disability

• Partners in Care Foundation

• Healthy Living Center of Excellence

• Independent Living Research Utilz.

• Stanford CDSMP

• A Matter of Balance

• Healthy IDEAS

• PEARLS

• Fit & Strong

• EnhanceWellness

• EnhanceFitness

• HomeMeds

• Healthy Moves

aginganddisabilitybusinessinstit

ute.org

Questions?

Contact Partners in Care Foundation

− June Simmons, CEO Partners in Care Foundation

• 818.837-3775 ext 155 • jsimmons@picf.org

www.picf.org; www.HomeMeds.org