Gauging the Value of AAA Services: Results from a New

Poll & AAA Perspectives

Part of the Aging and Disability Business

Institute Series- a collaboration of n4a and ASA

Mary Kaschak, Deputy Director, Aging and Disability Business Institute, n4a Meredith Hanley, Director, Community Capacity Building, n4a Christine Vanlandingham, Fund and Product Development Officer, Region IV Area Agency on Aging David Kelly, Executive Director, Area Agency on Aging and Disabilities of Southwest Washington

The “Business Institute”

The mission of the Aging and Disability Business Institute (Business Institute) is to successfully build and strengthen partnerships between community-based organizations (CBOs) and the health care system so older adults and people with disabilities will have access to services and supports that will enable them to live with dignity and independence in their homes and communities as long as possible.

www.n4a.org/businessinstitute

Partners and Funders

Partners:

• National Association of Area Agencies on Aging

• Independent Living Research Utilization/National Center for Aging and Disability

• American Society on Aging

• Partners in Care Foundation

• Elder Services of the Merrimack Valley/Healthy Living Center of Excellence

Funders:

• Administration for Community Living

• The John A. Hartford Foundation

• The SCAN Foundation

• The Gary and Mary West Foundation

• The Colorado Health Foundation

• The Marin Community Foundation

New Report: Measuring the Value of AAA Services Making the Case to Health Care Partners

About the Survey

• Funded through the Administration for Community Living

• Brief poll was conducted between November 2017 and January 2018.

• 4 in-depth interviews with respondents

• Purpose was to find out: • Extent to which AAAs estimate or measure the

value of their services • What methods they use to estimate or measure

value

Tracking the ROI of Individual Programs is the Most Common Way AAAs Measure the Value of Their Services

• 28 percent of AAA respondents currently measure the financial value of AAA services

ROI is Most Commonly Calculated for Case Management and Evidence-Based Programs

AAAs Using Financial Value Data to Make a Better Business Case

Measuring Value Helps AAAs Secure Funding

IT Infrastructure is a Challenge for Calculating Financial Value of Services

Conclusions

• AAAs have begun to recognize the importance of value measurement as an important tool in approaching health care partners for contracts.

• Training and technical assistance are needed in this area, particularly on IT and data systems.

Using Data to Find Sources of Sustainable Funding

ASA Webinar Tuesday, July 17, 2018

Christine Vanlandingham, Fund & Product Development Officer Region IV Area Agency on Aging, St. Joseph, MI

HBC Membership: Area Agency on Aging Berrien County Dept. of Human Services Berrien County Health Department Berrien County Medical Society Cassopolis Family Clinic (FQHC) Consortium for Community Development Hospice At Home InterCare Community Health Network

(FQHC) LakelandHealth (Health System) Riverwood Mental Health Authority United Way Various Community Leaders

Where we started…

Interagency Care Team

(ICT) A project initiated by

Healthy Berrien Consortium:

A data-driven group of CEOs from key health care organizations formed to jointly undertake improving

the health and well-being of Berrien County residents.

The issue:

Older adults with multiple chronic conditions experience some of the worst health outcomes in the region.

Strategies: • Coordinated Care Management encompassing

primary care, acute, specialty and home and community based services

• Web-based communication tool linking

professionals involved with patient allows multiple agencies to coordinate care and share

progress notes towards common goals.

Interagency Care Team (ICT) Purpose:

To link persons with multiple chronic health conditions with flexible interagency care teams that promote self-direction and person-centered planning to achieve positive health outcomes.

HBC Aging Subcommittee:

Target population…

Targeting criteria: • persons dually eligible for Medicare and

Medicaid, • co-morbidities of 3 or more chronic diseases or

conditions • frequency and volume of hospitalization and/or

ED visits • consideration of the involvement of a Primary

Care Physician • persons seen as likely to benefit from the

intervention

Value Expectations…

Stabilized Health for Seniors with Multiple Chronic

Diseases

Increased Caregiver and Social Support

Reduced Hospitalization/ED visits Increased Primary Care

& HCBS

Sustainability through Establishment of Payment

Model

ICT Project Key Elements

Patients & Caregivers

Providers (Health and Social

Services) Resources Technology Process

In-Home Assessment, Health Benefits Counseling

& Health Coach visits/access to

HCBS

Aligned objectives

Interagency Care Team including CM functions

across health and social service sectors

Web-based Care Management

communication tool

Improved Care Coordination

i i i i

Chronic Disease Self-Management

Training

Access to timely data/information

sharing across health and social services

sectors

Community Roadmap of full array of health

and social services and supports

Chronic Disease Management

i i

Caregiver education and support

Barrier identification/home stabilization

i i

Improved population

health f f f

Coordinated care management/increased

monitoring to reduce unnecessary care and

utilization of appropriate setting of care

i

Reduced cost

= AAA Role

Data – the key to driving change…

External Evaluation • Evaluation model design led by

Public Health Department Epidemiologist

• External project evaluator (contracted) overseen by Public Health

• Data collected by agency partners • evaluated by external

evaluator • results drive project

evolution • informed sustainable

payment model development

ICT pt. demographics

Identify/Address barriers to improved health

ICT Pts.

Identify/Address barriers to improved health

ICT Pts.

iEval report:

91% of barriers were resolved

through coordination of care and

connection to community

resources, services and

supports.

Study – Plan – Test

Body of evidence demonstrates need

Broad coalition develop solution

One-year beta test showed solution effective

Healthy Berrien Consortium Berrien County Health Dept. Area Agency on Aging Lakeland Health

InterCare (FQHC)

Implementation

Implementation funding secured

Berrien Health Plan (2015)

Berrien Health Plan Healthy Berrien Consortium Berrien County Health Dept. Area Agency on Aging Lakeland Health

InterCare (FQHC)

Riverwood (CMH)

Gaps identified Sustainable Service

Key outcome: Development and implementation of payment model

Interagency Care Team Project

Project Coordinator /

Project Evaluator

Salary Support

In-home Health

Coaching/Barrier

Identification/HCBS

(AAA)

In-home Pharmacy

consultations (Health

System)

In–home Nutrition

Education (AAA)

Payment Model

Consultant

IT tool refinement

Progress toward goals: Sustainability

Goal: Provision of a cost-benefit analysis design and potential payment

model to be used for project expansion, sustainability and replicability.

Study – Plan – Test

Body of evidence demonstrates need

Broad coalition develop solution

One-year beta test showed solution effective

Healthy Berrien Consortium Berrien County Health Dept. Area Agency on Aging Lakeland Health

InterCare

Riverwood

Implementation

Implementation funding secured

Berrien Health Plan (2015)

Berrien Health Plan Healthy Berrien Consortium Berrien County Health Dept. Area Agency on Aging Lakeland Health

InterCare

Riverwood

Sustainable Service

Funding Secured for on- going services through December 2018

Key outcome: Development and implementation of payment model & executed contract(s) for sustained service.

Interagency Care Team Project

Progress toward goals: Sustainability

Goal #3: Provision of a cost-benefit analysis design and potential payment model

to be used for project expansion, sustainability and replicability.

Gap funding secured

United Way

Local Family Foundation

Two Community Foundations

Michigan Health Endowment Fund

Improve health outcomes and reduce costs - iEval report

6 months post ICT intervention Patient survey results: • Pts indicate “I know who to call if I am getting worse or feeling bad”

(100%)

• Pts indicate that rather than immediately presenting to the ER, he/she would telephone a known contact for advice first. (86%)

• Only one patient thought they would definitely be going to the ER or hospital in the next 30 days

6 month post ICT intervention Cost Evaluation report:

• After the first six months of enrollment, the overall costs for all 38 patients decreased by 36%. (Sept. 2017 iEval Report)

ICT AAA Services: Health coaching; Care management; Medical Nutrition

Therapy; Program Development; Project Administration; Fiduciary

ICT Payment Structure: Initially self-funded by partners: AAA, hospital, PCP groups, FQHCs, Health

Dept., other Current:

Foundation(s) - 4 local entities funding services, evaluation & payment model development for scalability; Medicare –Medical Nutrition Therapy (MNT);

Planned – bundled payment for flexible team participation, FFS for distinct

Medicare billable codes

Where we are now…

• Obtained Medicare Provider Number in 2017

• Currently billing Medicare directly for MNT

• Contract executed with Lakeland Housecalls, July 2018:

For Medicare Billable Services:

• Transitional Care Management (TCM) 99495 & 99496

• Chronic Care Management (CCM) 99490

• Complex Chronic Care Management & add on 99487 & 99489

• Behavioral Health Integration (BHI) • Collaborative Care Management (CoCM) 99492 & 99493

• Other contracts under development with RHC and FQHC

Payment Models differ with each partner:

Contracts under development with:

• Rural Health Clinic -

• Transitional Care Management (TCM)

• Chronic Care Management (CCM)

• Federally Qualified Health Center -

• Chronic Care Management (CCM)

• Complex Chronic Care Management

One size does not fit all…

Implications/Considerations going forward

• Technology

• EMR - EPIC/Next Gen/other?

• Communication tool - ResourceConnection

• Billing

• Contractual arrangements – ability to document encounters and capture/communicate data with partners

• Direct Medicare billing – currently paper process; scaling up will require exploration of billing partner or billing software/service

• Possible establishment of subsidiary or LLC to accommodate growth

• Recruitment of Board expertise

Working As a CBO to Impact Health Outcomes:

The Magic Sauce of At-Home In-Person Community Based

Case Management

David Kelly Executive Director,

Area Agency on Aging and Disabilities of

Southwest Washington

Introduction

• Executive Director of the Area Agency on Aging & Disabilities of Southwest Washington (AAADSW).

• AAADSW serves five counties in Southwest Washington.

- 160 employees

- Manage and assure compliance of 100+ Contracts

- Operating budget of $17,500,000

- Plan and Advocate for Southwest Washington Seniors,

Adults with Disabilities and Family Caregivers

• We are one of thirteen Area Agencies on Aging (AAAs) in Washington.

• Washington AAAs are primarily local government agencies governed by local elected officials.

• Our mission is to promote independence, choice, well-being, and dignity for older adults, adults with disabilities and family caregivers in our five-county Planning and Service Area (PSA) through a comprehensive, coordinated system of home and community-based services.

AAADSW Programs

• Medicaid Case Management (Title XIX)

• Care Coordination/Transitional Care

• Older Americans Act & Community Based Programs

AAADSW’s Participation in Washington State’s Health Home Program

• AAADSW is a Care Coordination Organization (CCO)

• Amazing program impacting lives

• Addressing one-on-one the social determinants

of health

• Terrific Public/Private partnerships

• Evidence Based savings of $67 Million 1

Notes: • Savings based on the first two years of the program

• Savings are from dually-eligible Medicare/Medicaid clients only

• Assumption made of similar savings from Medicaid-only clients

• Savings are w/o contributions from King and Snohomish Counties

Health Home History • Affordable Care Act authorized HH programs that

“…give states an opportunity to improve care coordination and care management for Medicaid beneficiaries with complex needs…CMS and the Washington State Health by better care coordinating care and linking people to needed services, [all] designed to improve health care quality and reduce costs.”

• CMS and the Washington State Health Care Authority launched the Washington Health Home managed fee-for-service model demonstration in 2013.

• To date, twenty states have created HH models. Washington’s model targets high risk patients/enrollees with chronic illnesses who are responsible for more than 85% of Medicaid spending.

AAADSW’s Care Coordination History

• Program launched in 2013

• Today we have close to 40 Care Coordination team members

• With thousands of referrals received to date from various Health Home Leads (MCOs) we have achieved nearly a 40% client engagement rate, compared to the national average of 9%

• Over 1,500 clients actively engaged with Care Coordination Health Action Plans

Approximately 30% of those are actively receiving LTSS

Approximately 75% are dually eligible

Basic Health Home Operational Concepts

• FOCUS ON ACTIVELY ADDRESSING SOCIAL DETERMINANTS OF HEALTH

• Medicaid enrollees face multiple issues (i.e. housing) termed “other” social determinants of health. Connecting clients to community resources that alleviate obstacles improves well-being and avoids expensive treatments for preventable consequences of unmanaged conditions.

• TARGETED OUTCOMES OF THE HEALTH Home PROGRAM ARE TO:

Reduce service duplication

Provide seamless transitions from in-patient and facility stays

Facilitate personalized and person-centered care

Reduce chronic disease

Reduce emergency department utilization

Reduce preventable hospital readmissions

Improve health and self-management of conditions

Basic Health Home Operational Concepts

• Clients are obtained through

The Washington Health Care Authority uses a predictive risk algorithm to identify potential clients with higher health care costs (PRISM).

Potential clients are assigned to HH lead organizations who, through smart assignment process referrals to local CCOs.

CCO staff contact the potential clients. These “cold calls” generate a success measurement (the “engagement rate”) when clients accept coordination services and produce a client-driven Health Action Plan (HAP)

HUGE Health Home Success

• Dual eligible Medicare savings from the first 30 months of Health Home program operations (July 2013 to December 2015) 1

– $67 million in total Medicare savings

– Up to 50% of savings are shared with the State, depending on Medicaid cost impacts and performance on quality metrics

– To date, HCA has received approximately $20 million in payments for Medicare savings achieved

– In 2017 the Legislature approved sharing savings with Health Home Leads who meet engagement goals

Why Health Home Success?

• Built Upon Washington State’s Past Successes

• Highly successful LTSS program, ranked #1 by AARP in 2017, ranked 35th in costs 2

• 30 years of Medicaid Title XIX case management expertise

• Highly Successful Chronic Care Management Program Used as Baseline Program 3

• Specific Expertise & Methods Used, Including: • High quality trained staff to interact with clients • At home care coordination • Client directed care coordination • Conflict free care coordination

Difficulties in Start Up Mode

Why the success at AAADSW

A 2017 independent review of AAADSW’s Care Coordination Organization conducted as a one year Capstone study by MBA students from Oregon Health Sciences University (OHSU) identified the following “best practices” for those performing the Health Home work 4, 5

AAADSW’s Best Practices for Care Coordination 1. Face-to-face contact

2. Realistic case loads

3. Broad and diverse connectivity

4. Close ties to related organizations

5. Continuous refinement of practices

6. Separation of financial interests

7. Staff training

8. Task specialization

9. Staff retention

10. Information technology

11. Willingness to risk fund balance

Further Evidence of Health Home Success

From a study published by David Mancuso, PhD, entitled Washington State’s Health Home Program: Engagement Rates and Medicare Savings Outcomes 6

[David Mancuso, PhD, Director, DSHS Research and Data Analysis Division, October 19, 2017]

Since the Health Home program was initiated, for

example, Ambulatory Care-Sensitive Hospital

admissions were reduced by 33.3%.

The real success is in the lives impacted

• In an October 2017 press release Washington Governor Jay Inslee shared a very moving story about how a Health Home Care Coordinator impacted the life of a Spokane, Washington citizen. 7

• Real stories of success shared by Care Coordinators who love and appreciate the opportunity they have to impact and help clients improve their lives.

“Frequent monthly visitor to the ER now has basic needs met resulting in no

more unnecessary ER visits.”

“Homeless man with difficult background now trusting a doctor.”

“Skilled nursing facility resident able to hear and communicate with her facility family.”

“Vulnerable and financially exploited woman increasing her confidence to make

better decisions for her well-being.”

“Suicidal woman now able to obtain identification necessary to receive benefits and manage her own monies for her care.”

My interactions with AAADSW Care Coordinators feedback/input

Other AAADSW Program Innovations

Stemming from our success in the Care Coordination program, AAADSW has implemented several innovative programs to address the social determinants of health and improve health outcomes

• Transitional Care Services

• Technology to Support Aging In Place (TSAP)

• Geriatrics Workforce Enhancement Center (GWEC)

Qualis Study on AAADSW’s Care Transitions Program8

• TSAP is a remote client monitoring program emphasizing client education and chronic illness self-management.

• Program implemented by AAADSW in January 2016 within the Care Coordination client community.

• Of 288 Care Coordination clients contacted, 62 agreed to be part of the pilot program (27%).

• Pilot program was studied by researchers from the WSU Department of Human Development; Prevention Science Graduate Program, and the College of Nursing.

• Primary expenses for the project included a project coordinator and 78 sets of remoted monitoring devices.

• CCO staff time and AAADSW administrative time were not monitored as a part of project expenses.

Technology to Support Aging in Place

Is TSAP associated with fewer hospital admissions?

• Hospital admissions among participants were reduced by 54%.

• From 1.12 admissions per patient year to 0.51 admissions.

• Days spent in hospital by participants were reduced by 57%.

• From 3 days per patient year to 1.3 days.

Geriatrics Workforce Enhancement Center

• Partner with University of Washington

• Bridging the Clinical-Community Gap

• A unique experience offers medical school residents and health professionals first-hand exposure to the Aging network.

• Connecting the primary care workforce to community-based resources

• Partnerships with two Area Agencies on Aging: - Area Agency on Aging & Disabilities of Southwest Washington (Rural) - Aging & Disability Services of King County (Urban)

GWEC Program

Experiential Visits include:

• Accompanying case managers on home visits

• Shadowing family caregiver specialists

• Working alongside our care coordinators

• Observing our information & assistance advocates

The GWEC Experience • 24 GWEC participants have completed the practicum to

date.

• 100% of GWEC participants rated they were highly satisfied (4 or 5 rating on a 5-point scale).

• After practicum, GWEC participants felt more confident in their ability to:

- describe the role of an AAA case manager. - describe the Aging network and the role of AAAs. - identify and refer to evidence-based health promotion programs. - identify the signs of elder abuse and prevent or address it.

• 100% of GWEC participants would change their practice of caring for older adults based on this Practicum experience.

Future of Health Home in Washington State Could these programs be national models for

addressing social determinants of health? HUGE THANK YOU to Washington State

legislators for having part of cost savings dollars received directed to help offset costs (engagement rate bonus)

HUGE CHALLENGE TO ADD dollars to the basic

rate to enable other agencies to fully participate

Footnotes and citations

1. https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/WAEvalMedicareCostYr1FinalYr2Preliminary072817.pdf

2. http://longtermscorecard.org/

3. http://content.healthaffairs.org/content/34/4/653.full.html

4. Best Practices for Care Coordination: The AAADSW Model. Paul Wilkens, Rick Pittman, M.D., James Heilman, M.D., Tiffany Charleston, and Michael Meyers

5. https://stateofreform.com/news/2017/11/washingtons-health-home-program-standout/

6. http://www.helpingelders.org/download/7786/

7. https://medium.com/wagovernor/obamacare-based-program-gives-high-risk-patients-better-care-saves-money-95220df796d6

8. http://www.helpingelders.org/download/9796/

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