San DiegoLong Term Care Integration Project

San Diego Psychiatric Society

Presentation

December 9, 2003

Community Planning Process

From 50 to 450+ key stakeholders over past 4 years: 10,000+ hours

Seeking to improve system of care for consumers and providers (SDCMS on mailing list and Advisory Group)

Agreement to use existing providers, assure fair compensation

Planning within state LTCIP authorization (form follows funding)

San Diego County Board of Supervisors&

State Office of Long Term Care

Rodger G. Lum, Ph.D, DirectorCounty of San Diego, Health & Human Services

Agency, (HHSA)

Advisory Group:Goal: Make final decisions and

recommendations for inclusion in the plan.

Planning Committee:Goal: Guide the LTCIP planning process.

GovernanceWorkgroup

GovernanceWorkgroup Case Management

Workgroup

Case Management Workgroup Finance/Data

Workgroup

Finance/DataWorkgroup Information Technology

Workgroup

Information TechnologyWorkgroup

Internet• -Facilitates

communication• -Provides broad public

education

Pamela B. Smith, Project DirectorAging & Independence Services

Lead County Agency

Quality AssuranceWorkgroup

Quality AssuranceWorkgroup

Develop a model thatsupports integration acrossthe continuum of care to ensureeasy access to care & services.

Determine the financialfeasibility of the proposedLTCIP for San Diego County.

Determine consumerprotection & qualityassurance standards &requirement for the LTCIP.

Identify the information &technology requirementsneeded to support a LTCIdelivery system.

Develop a recommendationfor the governance structurefor the implementation phaseof the LTCIP.

Workforce IssuesWorkgroup

Workforce IssuesWorkgroup

Increase the number of trained providers across the long term care continuum workforce, with an emphasis on quality care.

Long Term Care Integration Project Organizational Chart & Decision

Tree

San Diego Stakeholder LTCIP Vision for Elderly & Disabled Develop “system” that:

– provides continuum of health, social and support services that “wrap around consumer” w/prevention & early intervention focus

– pools associated (categorical) funding– is consumer driven and responsive– expands access to/options for care

Stakeholder Vision (continued)

– Fairly compensates all providers w/rate structure developed locally

– Engages MD as pivotal team member– Decreases fragmentation/duplication

w/single point of entry, single plan of care– Improves quality & is budget neutral– Implements Olmstead Decision locally– Maximizes federal and state funding

Managed Care vs Integrated Care

Managed Care:– Insurance companies manage cost of

cases, may interfere w/MD treatment plan– Prevention activities on population basis

only– Often restricts choice and options– Many consumers unable to be adequate

self-advocates

“Integrated Care”

Population & individual prevention programs Chronic care management by “team” at home

for those identified at high risk Service delivery at lowest level of acuity Across Medicare & Medi-Cal Across health & social services Flexibility for consumer due to pooled funding Maximize public resources to develop new

system for all (us!)

Why? Mrs. C:

84 yo woman lives alone CVA, HTN, depression, ADL and IADL

dependencies 16 medications by 6 MDs, including

psychiatrist Medicare and Medi-Cal beneficiary Only child lives in Chicago

Client Referral Patterns

CUSTOMER ACCESS with LTCIP

Customer At Home/Community

Care Manager w/ Network of Care

IncomeAsst.

SeniorCntr.

In-homecare

HICAP

MedicalClinic

BloodPressure

Cks

ShoppingAsst. rehab

Transp.Escort

housing

Health Care

Intake Worker InformationProvided

Legislative Authority

AB 1040 in 1995 (revised in 1998) State Office of LTC:

– provides planning $$– provides “Center” resources– provides liaison with other state programs– approves local activity toward LTCI– will assist in procuring federal waivers

Statement of Need Aging Population

– San Diego County to increase significantly• Elderly:14% today; 25-33% by 2030• From 1990 and 2010, 75+ increases by 81%• 85+/minority elderly:fastest growing segments

– 60% of those 65+ will require long term care services at some point

– Those who need service can’t find it– Care is fragmented by regulation!– Providers asked to do more w/less

Statement of Need (cont’d) Expenditures

– LTC recipients represent: 25% of Medicaid population, 67% of Medicaid expenditures

• San Diego ABD enrollees/month - 95,000 • 62% dually eligible (Medi-Medi)• 90% of those 65+ are dually eligible• Annual expenditures

– Medi-Cal: $520,114,276 (CY 2000)

– Medicare: $377,828,473 (CY 2000)

– Only 7% of US population currently has private LTC insurance (narrow population can benefit)

– Resources insufficient to meet future demand

From Vision to Service Delivery Model… Explore Healthy San Diego due to:

– Access, education, prevention– Advocacy– Cost-effectiveness– Population-based– Existing infrastructure– Stakeholder-designed, BUT

HSD Currently Does NOT…

Tailor the program for chronic care or aged and disabled persons

Provide “wraparound” services Provide chronic care management on a

population basis Receive adequate reimbursement for

chronic care Have much info on “duals”

Where are we now?

Last year, BOS: “come back with 3 options” next Spring (MDs & AARP)

Since then: Dr. Mark Meiners and 3 strategies development

Expert consultant team proposal MassHealth SCO exploration Administrative Action Plan underway

What about Mental Health & Substance Abuse? Current Medi-Cal carve-out (UBH) Limited Medicare reimbursement LTCIP stakeholders want no carve-outs Quality of life and financial impact of untreated

mental illness is huge Inadequate resources for MHSA (1915c waiver?) Most integration projects do not enroll disabled

w/primary MH diagnosis

What about MH & SA (cont.)

Aged/disabled persons do not use MH Centers

Elderly do not self-identify as having MHSA needs

MassSCO plan: postpone primary MHSA inclusion until successfully implementing plan for elderly

Waiver could designate psychiatrist as PCP

LTCIP Mental Health Workgroup Goal: recommendation to Planning

Committee on inclusion of MH services Chair: Dr. Margaret McCahill Membership extended to all Next Mtg: Jan. 7, 2004, 4 to 5:30 PM to

review progress of working committee Place: Pt. Loma Nazarene University,

Mission Valley

Why should mental health stakeholders get involved?

To influence planning and decisions To impact delivery of acute & LTC

needs of individuals (support+services) To ensure plan integrates primary,

acute, social, and support services

How can you influence planning?

Get on LTCIP mailing list for updates

Participate in Planning Committee and Workgroup meetings

Log onto website for background & info: www.sdcounty.ca.gov/cnty/cntydepts/health/ais/ltc

Call 858-495-5428 or e-mail on-going input/ideas: evalyn.greb@sdcounty.ca.gov