health homes for people with chronic conditions: a discussion with dr. moser
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Health Homes for People with Chronic
Conditions: A Discussion with Dr.
Moser
10/24/2013 Dr. Robert Moser Webinar
KANSAS HEALTH HOMES DEVELOPMENT
• Spring 2012
• State Project Team
• University Partners
• Focus Group
• Learning Collaborative
• Steering Committee
10/24/2013 Dr. Robert Moser Webinar
• The term “health home” is unique to Medicaid• A health home is a comprehensive and intense
system of care coordination that integrates and coordinates all services and supports for people with complex chronic conditions
• Intended for people with certain chronic conditions
INTRODUCTION
10/24/2013 Dr. Robert Moser Webinar
68% of people with mental illness have one or more co-occurring conditions
• Asthma • Diabetes• High blood pressure• Heart Disease• Obesity
People with mental illness die earlier than the general population
Substance Abuse and Mental Health Services Administration
THE PROBLEM
10/24/2013 Dr. Robert Moser Webinar
• Diabetes prevalence adult beneficiaries
– 20.5% (N=37,577)
• Net payment by Kansas Medicaid
– $559,307,804 (36.1% of total expenses)
– $14,884/person
Data for fee-for-service enrollees
DIABETES IN MEDICAID (FY 2011)
10/24/2013 Dr. Robert Moser Webinar
WAYS TO INTEGRATE CARE
• Facilitated referrals between PCP or behavioral health provider and other providers
• Co-location of physical health clinician in behavioral health agency or vice versa
• Full integration of physical and behavioral health clinicians in one agency/building
• All three ways are acceptable in health homes initiative as long as existing consumer-provider relationship not disrupted
10/24/2013 Dr. Robert Moser Webinar
HOW HEALTH HOMES IMPROVE HEALTH
Health homes ensure:• Critical information is shared among providers and with
consumer• Consumer has tools needed to help manage his chronic
condition• Necessary screenings and tests occur timely• Unnecessary emergency room visits and hospital stays
are avoided• Community and social supports are in place to help
maintain health
10/24/2013 Dr. Robert Moser Webinar
EARLY RESULTS FROM MISSOURI (2011 to 2012)
• Patients with at least one hospitalization decreased from :– 23.9% to 15.7% in primary care health homes– 33.7% to 24.6% in Community Mental Health
Center health homes
• Overall reduction is 12.8% per 1000 admissions
SAMHSA-HRSA Center for Integrated Health Solutions webinar 6/27/2013
10/24/2013 Dr. Robert Moser Webinar
EARLY RESULTS FROM MISSOURI (2011 TO 2012)
• Reduced ER use by 8.2% per 1000
• Net savings in ER and hospital costs - $48.81 per health home member per month (PMPM)
• Total Medicaid net savings $83.26 PMPM
SAMHSA-HRSA Center for Integrated Health Solutions webinar 6/27/2013
10/24/2013 Dr. Robert Moser Webinar
Model 1
Designated Provider
Model 2
Team of Health Professionals
Model 3
Health Team
THREE FEDERAL HEALTH HOME MODELS
10/24/2013 Dr. Robert Moser Webinar
A Team of Health Professionals: May include physician, nurse care coordinator, nutritionist, social worker, behavioral health professional, and can be free standing, virtual, hospital‐based, community mental health centers, etc.
KANSAS MODEL
10/24/2013 Dr. Robert Moser Webinar
Person must be eligible for Medicaid, and have at least:
•Two chronic conditions;
•One chronic condition and is at risk for another chronic condition; or
•One serious and persistent mental illness
FEDERAL ELIGIBILITY FOR HEALTH HOMES
10/24/2013 Dr. Robert Moser Webinar
• Mental health condition• Substance use disorder• Asthma • Diabetes• Heart disease• Being overweight, as evidenced by a body mass index
over 25. • Section 1945(h)(2) of the ACA authorizes the Secretary
to expand the list of chronic conditions
CHRONIC CONDITIONS
10/24/2013 Dr. Robert Moser Webinar
• Comprehensive care management• Care coordination• Health promotion• Comprehensive transitional care, including appropriate
follow-up, from inpatient to other settings• Individual and family support (including authorized
representative)• Referral to community and social support services, if
relevant
SIX CORE SERVICES
10/24/2013 Dr. Robert Moser Webinar
• To “link services”
• Quality reporting
• Provider supports/requirements
• Facilitate communication and feedback to/among providers and consumers
ROLE OF HIT
10/24/2013 Dr. Robert Moser Webinar
KANCARE HEALTH HOME MODEL
Medicaid Agency
MCO
MCO
MCO
CIL
CMHC
PCP
Safety Net Clinic
SUD
CDDO
Other
Recipient
Recipient
Recipient
Recipient
Recipient
Recipient
Recipient
MCO staff + third party = HH
Dr. Robert Moser Webinar10/24/2013
• A partnership between the managed care organization (MCO) and another entity (Health Home Partner – HHP) that is appropriate for the consumer
• Health home recipients likely have experience with, and preferences for, different types of HHPs depending upon where they live and what Medicaid population they belong to
KANCARE HEALTH HOME MODEL
10/24/2013 Dr. Robert Moser Webinar
SERVICE STRUCTURE
HH Partner(HHP)
Individual and Family
Supports
Health Promotion
Comprehensive care
management
Referral to community and social supports
Care Coordination
Comprehensive transitional
care
MCO
Member with
designated condition
10/24/2013 Dr. Robert Moser Webinar
PARTNERING TO PROVIDE SERVICES
• Some health home services provided by the MCOs and some by the Health Home Partner (HHP)
• Division of services, as well as payment between the MCO and the HHP, will be spelled out in contract between the MCO and HHP
• HHP may contract for one or more services with another provider
10/24/2013 Dr. Robert Moser Webinar
HEALTH HOMES PAYMENT PRINCIPLES AND PARAMETERS
• State PMPM payments to the MCOs will be adequate to ensure quality services
• MCO payments to HHPs will be adequate to ensure sustainability and quality of services
• State health home payments to the MCOs will be actuarially sound
10/24/2013 Dr. Robert Moser Webinar
KANCARE HEALTH HOMES GOALS
• Reduce utilization associated with inpatient stays
• Improve management of chronic conditions
• Improve care coordination
• Improve transitions of care among primary care and community providers and inpatient facilities
10/24/2013 Dr. Robert Moser Webinar
CMS CORE MEASURES
• Adult BMI assessment
• Ambulatory care – sensitive condition admission
• Care transition – transition record transmitted to health care professional
• Follow-up after hospitalization for mental illness
10/24/2013 Dr. Robert Moser Webinar
CMS CORE MEASURES
• All cause readmission
• Screening for clinical depression and follow-up plan
• Initiation and engagement of alcohol and other drug dependence treatment
• Controlling high blood pressure
10/24/2013 Dr. Robert Moser Webinar
TARGET POPULATIONS
• One target population is people with serious mental illness (SMI)
• Another target population yet to be determined, but will include people with diabetes
• Can’t exclude dual eligibles or limit to a particular age group
• All HH members must be in KanCare and must select a HHP within MCO network
10/24/2013 Dr. Robert Moser Webinar
ENROLLMENT
• Passive enrollment with “opt out” feature
• Enrollee will receive a letter and have to choose to opt out
• Must have a choice of health home provider, but may be limited to certain number of times in a year
• Grievance and appeal rights
10/24/2013 Dr. Robert Moser Webinar
WHERE WE ARE
• Engaging stakeholders• First SPA drafted• Consultation with SAMHSA complete• Monthly calls with CMS• Working on operational issues• Analyzing data to designate target population for
second SPA• Implement HHs for both target group (SMI and
other chronic conditions) July 1, 2014
10/24/2013 Dr. Robert Moser Webinar
QUESTIONS?
10/24/2013 Dr. Robert Moser Webinar
NEED MORE INFORMATION?
Becky Ross, Medicaid Initiatives Coordinator
Division of Health Care Finance
Kansas Department of Health & Environment
rross@kdheks.gov
10/24/2013 Dr. Robert Moser Webinar
www.kancare.ks.gov
10/24/2013 Dr. Robert Moser Webinar
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