Aligning Federal and State Approaches to Integrating Primary Care and

Community Resources

December 9, 2013 This webcast will begin at 12:30 pm Eastern.

The audio portion of this event will be broadcast through your

speakers. You may also access it by dialing 800 403 7802

This event is sponsored by The Commonwealth Fund. 1

l  Emerging models link primary care providers to community resources and services l  Patient-centered care with a whole-person orientation l  Link to behavioral, public health, long-term services and

socio-economic supports and services l  State and federal policy levers can facilitate linkages

l  Oversight and regulatory roles l  Resources l  Financing and purchasing roles

l  Greater federal/state alignment will foster shared goals for integration and enable new innovations

Background

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Today’s Agenda 12:30 – 12:40 pm Welcome and Introductions

Jill Rosenthal, Senior Program Director, National Academy for State Health Policy (NASHP)

12:40 – 1:10 pm State Strategies for Integrating Primary Care and Community Resources Robert Moon, Chief Medical Officer and Deputy Commissioner, Health Systems, Alabama Medicaid Deidre Gifford, Medical Director, Rhode Island Medicaid

1:10 – 1:25 pm The Federal Perspective Suzanne Fields, Senior Advisor to the Administrator on Health Care Financing, Substance Abuse and Mental Health Services Administration Barbara Edwards, Director, Disabled & Elderly Programs Group, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services

1:25 – 1:55 pm Questions and Discussion 1:55 – 2:00 pm Wrap-up

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Primary Care /

Community Integration

Robert Moon, MD Chief Medical Officer and Deputy Commissioner,

Health Systems Alabama Medicaid Agency

NASHP Federal/State Discourse Webinar 12/9/13

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l  Regional care networks system of case management operated by 501 c 3 organizations.

l  Originally started under a 1915 B waiver in 8/2011.

l  Moved to Health home payment methodology 7/2012, but waiver was not approved until 3/2013.

Background

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1. Physical health case management: Nurses, social workers, community health workers working in coordinated regional teams to better manage qualifying individuals with chronic conditions 2. Interagency coordination 3. Community services coordination 4. Behavioral health: Behavioral health nurses work specifically for the regional care network to bridge the gap between physical health and behavioral health case management to make sure communication is bidirectional. 5. Medical Management Meetings: Network medical director coordinates quarterly meetings with primary care physicians. 6. Pharmacy Directors: Explore prescribing patterns with physicians, perform med reconciliations, and round in hospitals with transitional care nurse for improved care transitions.

Basic Structure/Functions

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Federal – State Alignment l  CMS have helped with the 1915 B waiver authority in

starting the Patient Care Networks of Alabama.

l  CMS and SAMHSA also helped when we moved the network authority from a 1915 B waiver to an ACA Section 2703 related SPA.

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Federal – State Barriers i.  Timeline

ii.  Start up funding

iii.  Need strong contract training

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Going Forward l  Building on existing infrastructure to develop a series of

ACOs covering the state.

l  Enhancing analytics capacity through adult quality metrics grant resources.

l  Developing competency in managed care through federal resources such as DOJ managed care training program hosted in South Carolina.

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Questions? / Comments!

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}  Multi-payer PCMH initiative: ◦  Began 2008 ◦  Includes all payers, including Medicaid MCOs and

FFS Medicare via the Medicare Advanced Primary Care Practice (MAPCP) demonstration program ◦  Standard FFS plus PMPM care management fee to

PCMH to support Nurse Care Manager (NCM) on-site and PCMH implementation ◦  Covers 260,000 adults in RI ◦  Two “Community Health Teams” to be piloted in

2014 ◦  Some sites have implemented on-site behavioral

health

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}  Two Health Home demonstrations in place: ◦  CEDARR (Comprehensive Evaluation Diagnosis

Assessment Referral Re-evaluation) for children with special healthcare needs

◦  Community Mental Health Organizations - for

individuals with a Serious and Persistent Mental Illness (SPMI)

}  Primary Care Case Management (PCCM) program for small FFS population: ◦  Pays PMPM to designated practices and supports

on-site Nurse Care Manager (NCM)

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}  Communities of Care: ◦  Medicaid MCO and PCCM program which identifies

high ED utilizers �  Includes member incentive for participation, pharmacy

lock-in, and Community Health Worker involvement �  Originally funded through grant.

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}  Workflow in primary care makes integration of “outside” resources challenging ◦  To be maximally effective, “community resources”

must be seen as part of the healthcare team ◦  NCM services on-site optimal. Financing in small

practices challenging. �  “Shared” NCMs ◦  Duplicate co-pays for on-site behavioral health and

primary care are a barrier ◦  Payment structures not seen as supporting on-site

behavioral health in primary care offices

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}  Nurse Care Managers need additional, non-RN support to handle the “community resources” function ◦  RNs often not working at “top of license” because of

need to connect clients to community resources ◦  Housing supports, behavioral health and substance

abuse issues are particularly acute need }  Communities of Care: ◦  Individuals who participated showed lower ED visit

rates in subsequent year than non-participants ◦  Member participation in incentives and care

management lower than hoped

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}  Health Homes: ◦  CEDARR provides community services for Children

with Special Health Needs (CSHN), but connections to primary care challenging �  Increase in parents self-reported knowledge of

community and condition specific resources �  Health Home requirement for quality indicator

measurement has helped establish connection �  FFS funding model does not support infrastructure to

connect primary care with CEDARR ◦  IT and workflow connections not well established: �  CEDARR enrollment data will soon be added to RI Child

Health Registry

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◦  Payments to primary care and to CEDARR do not support integration �  Need to better integrate CEDARR Health Home with

primary care has been part of impetus for pediatric PCMH initiative

◦  Currently evaluating experiment to place primary care in community mental health organization; preliminary lessons are that finances are challenging

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}  Linkages between primary care and community resources: ◦  Functional integration necessary for success. Takes

time and financial support. ◦  Workforce appropriate to work: not just RNs. ◦  Payments and metrics need to support

establishment of connections

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Aligning Federal and State Approaches to Integrating Primary Care and Community Resources

Suzanne Fields Senior Advisor to the Administrator

for Health Care Financing

Na#onal  Academy  for  State  Health  Policy  December  9,  2013  

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SAMHSA/HRSA Center for Integrated Health Solutions

•  www.integration.samhsa.gov •  Integrated Care Models •  Workforce •  Financing •  Clinical Practice •  Operations and Administration •  Health & Wellness •  2703 specific technical assistance

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Resources

•  Behavioral Health Homes for People with Mental Health & Substance Use Conditions: The Core Clinical Features http://www.integration.samhsa.gov/clinical-practice/CIHS_Health_Homes_Core_Clinical_Features.pdf

•  Financing and Policy Considerations for Medicaid Health Homes for Individuals with Behavioral Health Conditions: A Discussion of Selected States’ Approaches http://www.integration.samhsa.gov/integrated-care-models/Health_Homes_Financing_and_Policy_Considerations.pdf

•  Billing Sheets: identify existing billing opportunities for services provided in integrated settings http://www.cihslive.browsermedia.com/financing/

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Medicare Communication

•  Same day billing http://www.cms.gov/Outreach-and Education/Medicare-Learning-Network MLN/MLNProducts/MLN-Publications- Items/ICN908978.html

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Contact Information

Suzanne Fields, MSW, LICSW Senior Advisor to the Administrator for

Health Care Financing SAMHSA Suzanne.Fields@samhsa.hhs.gov 240-276-1838 www.SAMHSA.gov/healthreform

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Barbara Edwards Director, Disabled & Elderly Programs Group, Center for Medicaid and CHIP Services, Centers for Medicare & Medicaid Services

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v CMS Innovation Center Initiatives ü Accountable Care Organizations

•  http://innovation.cms.gov/initiatives/ACO/

ü Multi-Payer Advanced Primary Care Practice •  http://innovation.cms.gov/initiatives/Multi-Payer-Advanced-

Primary-Care-Practice/

ü State Innovation Models •  http://innovation.cms.gov/initiatives/State-Innovations/

CMS Innovation Center

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v 3 State Medicaid Director Letters ü Integrated Care Models – 7/10/2012

•  http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-001.pdf

ü Policy Considerations for Integrated Care Models – 7/10/2012

•  http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SMD-12-002.pdf

ü Shared Savings Methodologies – 8/30/2013 •  http://www.medicaid.gov/Federal-Policy-Guidance/Downloads/

SMD-13-005.pdf

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Payment Reform Opportunities

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v Health Home Information Resource Center ü Technical Assistance Services ü Peer-Learning Opportunities ü State Health Home Activity ü SPA Template ü Health Homes Guidance

•  Health Homes for Enrollees With Chronic Conditions – Nov 2010 •  Health Home Core Quality Measures SMD – Jan 2013

ü  http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html

ü  http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-Assistance/Health-Home-Information-Resource-Center.html

ü 

ü CHIP Program ü Medicaid MCOs ü Section 1937 non-managed care Alternative

Benefit Plans and benchmark equivalent plans v MHPAEA does not apply to State Plan

Services

Resources

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v Section 1115 Demonstrations – Medicaid.gov ü  http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-

Topics/Waivers/1115/Section-1115-Demonstrations.html v  Alternative Benefit Plans – Final Rule

ü  https://www.federalregister.gov/articles/2013/07/15/2013-16271/medicaid-and-childrens-health-insurance-programs-essential-health-benefits-in-alternative-benefit

v Managed Care Resources ü  http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-

Topics/Delivery-Systems/Managed-Care/Managed-Care.html ü MLTSS -

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Medicaid-Managed-Long-Term-Services-and-Supports-MLTSS.html

Resources

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Questions and Discussion

Please type your questions into the chat box.

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Additional Resources

l  NASHP Report: Federal and State Policy to Promote the Integration of Primary Care and Community Resources

l  NASHP Report: Aligning Federal and State Efforts on Payment Reform

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Thank you!

Your opinion is important to us. After the webinar ends, you will be redirected to a

web page containing a short survey. Your answers to the survey will help us as we

plan future NASHP webinars.

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