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CenterLightHealthcare.org
Managed Long Term Care:Considerations for Nursing Homes
LeadingAge Presentation
Swasti Apte, MHSAPatricia Leddy, MA, RN, LNHA
November 2013
Goals for Today
CenterLight Overview
Intro to MLTC
Market Landscape
Medicaid Redesign Team (MRT) Progress to date
Explore Synergies Between MLTC & Nursing Homes
Share Lessons Learned & Next Steps
New Considerations for Nursing Homes
New Care Models
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CENTERLIGHTHealthcare & Health System
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CenterLight Health System includes physical locations at which patients receive services, as well as CenterLight Healthcare, the MLTC organization that manages care for over 13,000 * individuals across nine counties.
• Home Health Care• Skilled Nursing and Rehabilitation
• Skilled Nursing and Rehabilitation
• PACE • Clinical Music Therapy• Skilled Nursing and Rehabilitation
• Skilled Nursing and Rehabilitation
• Adult Day Health Care Program
• Adult Day Health Care Program
• Select • Research• Adult Day Health Care Program
• Independent Housing• HIV / AIDS Home Care Program
• Direct • Education• Continuing Care Retirement Community (Skyline Commons)
• ParkchesterEnhancement Program (PEP) for Seniors
• Long Term Home Health Care Program
*As of September 2013. All membership totals are as of a point in time and subject to change as existing members disenroll and new members enroll.
4 skilled nursing facilities provide care for individuals needing rehabilitation services after surgical procedures and post-hospitalization with illnesses such as stroke or pneumonia, as well as care for the frail, elderly, or chronically ill in need of frequent medical attention and healthcare monitoring, in addition to other services like wound care and hospice
11 PACE centers provide primary care, including physician and nursing services; social services; restorative therapies, including physical therapy and occupational therapy; personal care and supportive services; nutritional services; nutritional counseling; recreational therapy; and meals
3 alternative care settings are an option for those PACE participants who prefer a smaller, more intimate setting to receive on-site socialization, social services, personal care services, therapeutic recreation, and meals
CenterLight Health System – Overview
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CenterLight Healthcare
Provider-sponsored Article 44 managed care organization (“MCO”)
Operating since 1985
PACE- largest and longest operating fully integrated program serving dual eligibles in NYS, and the largest PACE plan in the country
Select (Medicaid-only MLTC)
Direct (Institutional Special Needs Plan)
CenterLight Health System operates in nine counties: Bronx, Kings (Brooklyn), New York, Queens, Richmond (Staten Island), Nassau, Suffolk, Westchester, and Rockland
Services covered:
Primary, specialty, inpatient acute, and long-term care services and care management for the elderly, chronically ill, and disabled
CenterLight Healthcare is the only health plan in New York that includes an MLTC plan, a PACE plan, and a Medicare Advantage Institutional Special Needs plan (I-SNP)
CenterLight Healthcare is the largest component of CenterLight Health System.
CenterLight Health System
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MLTCIntroduction
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MLTC Patient
Must be able to stay safely at home at the time of enrollment.
Must be receiving or expected to need long-term care services for more than120 days. Majority of recipients are nursing home eligible.
Must meet the age requirement of the plan (18, 55 or 65, depending on the plan; almost all plans are now 18 and up)
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Nursing care Personal care Rehab (PT/OT/ST) Audiology & hearing aids Respiratory therapy Medical social services Nutritional counseling Chore services / housekeeping Home-delivered/congregate
meals Dental care Optometry/eyeglasses Podiatry
Transportation to health-related appointments
Durable medical equipment Nursing home care (restrictions
apply) Medical and social day care Personal Emergency Response
System (PERS) Assistance with mandated
Medicaid paperwork Patient teaching and health
promotion Social and environmental support Care management of covered and
non-covered services
Physician, hospital, ER, ambulance, diagnostic testing, lab, mental health, substance abuse, family planning services and hospice are not covered in the MLTCP benefit, although MLTCPs expect to be able to arrange for hospice services shortly.
MLTCP Covered Services
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Exempt Populations:
Residents of Assisted Living Programs, psychiatric facilities, long-term residential alcohol/substance abuse facilities, and OPWDD facilities
Individuals in the Traumatic Brain Injury and Nursing Home Transition and Diversion waiver programs.
Medicaid Managed Long Term Care Plans (MLTCPs)
Program of All‐inclusive Care for the Elderly (PACE)
Medicaid Advantage Plus (MAP)
Partially capitated for only Medicaid LTC services plus ancillary and ambulatory services (details on next slide)
No network requirements for physician or acute care
Are required to coordinate LTC and physician/hospital care
Fully at risk for both Medicare and Medicaid services
Members receive primary care via a PACE center
Combines Medicare Advantage Duals Special Needs Plan & MLTCP
Medicare capitation covers Medicare covered services
Medicaid capitation covers Medicaid covered services
NY’s 3 Current Managed Long Term Care Models
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MARKET LANDSCAPEThe World is Changing
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A demographic shift will drive growing demand. By 2040, there will be 80 million
individuals aged 65+, twice the number in 2011.
41% of all individuals aged 65+ report functional difficulty, which often requires long term care.1
Source: 1. Administration on Aging. A Profile of Older Americans: 2010.
Beyond Reform: Demographics Drive Demand
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Source: New York State Department of Health. (2011). Managed Long Term Care: The Next Steps. Presentation to the MRT Managed Long Term Care Implementation and Waiver Redesign Work Group on July 8, 2011.
While the per recipient expense increased for every category, MLTC’s increase was the lowest at 2.4%.
The Lewin Group report indicated that there was no marked difference in quality across groups.
# of Recipients Total ($) $ Per Recipient # of Recipients Total ($) $ Per Recipient
Nursing Homes 139,080 $5,946,989 $42,759 126,878 $6,429,336 $50,673 18.5%
ADHC 16,365 266,248 16,269 17,303 318,273 18,394 13.1%
LTHHCP 26,804 510,250 19,036 26,934 716,649 26,608 39.8%
Personal Care 84,823 1,824,729 21,512 72,031 2,152,439 29,882 38.9%
MLTC 12,293 444,341 36,146 37,843 1,401,362 37,031 2.4%
ALP 3,538 50,488 14,270 5,217 93,096 17,845 25.1%
Home Care/CHHA 92,553 760,347 8,215 87,366 1,551,546 17,759 116.2%
Total 318,617 $9,803,392 $30,769 320,590 $12,662,701 $39,498 28.4%
LTC Per Recipient Spending Trends by Service ($ 000)
2003 2010% Change In Per
Recipient Spending 2003 to 2010
Why Managed Long Term Care?
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Medicaid Global Cap drives new approaches to Medicaid budgeting in New York State
State limits traditional fee-for-service Medicaid to help meet the cap
Improving care management is major focus to address cost & quality concerns
Medicaid Reform
Duals are 15-20% of Medicare-Medicaid population, but account for up to 35% of spending
Major focus of federal Health Reform and State Medicaid reform
Duals in New York State requiring >120 days of long term care are required to join a managed long term care plan
Dual Eligibles
Payors are tying reimbursement to readmissions and outcomes, e.g., Medicare Value Based Purchasing, ACOs
Long term care providers that can demonstrate better performance have a stronger value proposition to upstream providers and payers
Value Based Reimbursement
Care coordination is the keystone of many new programs, e.g., FIDA, health homes, ACOs
Other emerging models of reimbursement require that providers work more collaboratively across the continuum of care, e.g., Bundled Payments
Integration & Coordination
Industry Trends
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Long Term Care Delivery
Industry Re-Alignment
Hospital & MD Systems
Forming Referral Networks
Nursing Home Consolidation
Re-aligning Providers
Reimbursement Pressure
(LHCSAs, CDPAP)
New Contracting Models (LTHHCP, ADHC, etc.)
Continuing Reform,
New Regulation,
Evolution of State & Federal Agencies (DOH, HRA, CMS)
Expanding Competition
Traditional & New MLTCs
(United, Aetna)
Other New Models
(Pioneer ACOs)
Consumer &
Labor Advocacy
(Fair Hearing, Living Wage)
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Reform Created A Shifting Landscape –No “New Normal” – Competition & Uncertainty
MEDICAID REDESIGNThe World is Changing
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Mandatory Enrollment commenced in the Fall of 2012.
As of Sep 2013, there are approximately 115,000 statewide enrollees in MLTC
To date, the following populations have been enrolled in MLTC
FFS recipients
Home attendant recipients
ADHC recipients
Lombardi recipients
CenterLight Healthcare has grown in membership from 7,990 to 13,066 between Aug ‘12 and Sept ‘13.
Source: Monthly DOH Enrollment File; http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/index.htm
Mandatory MLTC Enrollment
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Nursing home residents were initially excluded from the MRT’s mandatory enrollment initiative but as FIDA goes into effect, nursing home residents will be required to enroll into managed care plans.
Exempt population: ISNP
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MLTC Enrollment for Nursing Home Population
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Nursing Home Transition to Nursing Home Timeline
July 2015
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Additional Considerations for Transition of Nursing Homes Residents into Mandatory Enrollment
To assist with the transition, DOH has formed a Nursing Home Transition Workgroup (NHTW). This workgroup is further divided into 4 sub-groups, which focuses on a particular area of the NH transition:
1) Access to Care and Quality
2) Network and Contracting
3) Finance
4) Eligibility and Enrollment
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Access to Care and Quality Group Recommendations
► Plans will train and teach nursing homes about managed care
► Develop and share best practice models
► Develop a matrix that describes the specialty services and populations that each nursing home provides to better assist plans and hospitals to match members with facilities
► Quality Pool structure will include 14 quality metrics, compliance data, and potentially avoidable hospitalization data
Network and Contracting Recommendations► MCO network minimum requirements differ by county, ranging from 2 to 8
nursing homes to account for regional differences
► Plans will be required to contract with a minimum number of specialty nursing homes per county where it is available.
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Eligibility and Enrollment Phase-in Recommendations
► Develop workflows for each population and scenario
► Determine how requests for permanent placements are handled
► Eliminate lock-in for individuals in permanent nursing home placement
Finance Recommendations► Plans and providers can determinate rates if they can come to an
agreement; otherwise, plans will pay the nursing home the current FFS rate during the 2 year transition.
► New premium groups and rates will be established. These rates will reflect the introduction of new enrollees into MLTC
► Develop mechanisms to account for cost anomalies
► State will facilitate financial incentives for plans and providers to share savings
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FIDA Overview
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As a part of CMS’s national initiative to address dual eligibles, NYS created Fully Integrated Dual Advantage (FIDA), which builds from MLTC programs.
FIDA plans will receive both Medicare and Medicaid capitation to cover all medical, behavioral, and long term care services.
The demonstration will involve duals in an 8-county service area: The 5 NYC boroughs plus Nassau, Suffolk and Westchester counties.
The model of care is built around a inter-disciplinary team that includes caregiver, primary care provider, behavioral health aide, and participant.
Model includes a target population of both community based and long term nursing home participants
Expected to serve approximately 175,000 duals.
Expected cost savings of 1% from baseline in the first year, and continued increased savings there after
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Updated FIDA Timeline (based on 8/26 MOU)
Voluntary
Enrollment
Apr2014
Voluntary
Go-live
Passive
Enrollment
Passive Go-live
(phased over 4 months)
Beneficiaries allowed to enroll in any FIDA plan in service area
Remaining beneficiaries passively enrolled
Opt-out
Available
Beneficiaries can opt out during passive enrollment or any month after enrolled
Jul2014
Oct2014
Jan2015
Community‐based
Nursing Home
Apr2015
Voluntary
Enrollment
Voluntary
Go-live
Beneficiaries allowed to enroll in any FIDA plan in service area
Source: Memorandum of Understanding between CMS and NYSDOH, August 26, 2013
Sept Jan
Passive
Enrollment
Passive Go-live
(phased over 4 months)
Remaining beneficiaries passively enrolled
Opt-out
Available
Beneficiaries can opt out during passive enrollment or any month after enrolled
Jan Apr
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NEW CONSIDERATIONS FROM NURSING HOMES A Managed Care Perspective
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Future Impact of Managed Long Term Care On Nursing Homes
Downside
Reduced Need for Long Term Care Beds
Reduction in FFS Medicaid Payments
Increase Administrative costs to manage complexities of multiple plans
Shortened Length of Stay
Reduced Medicare Payments
Upside
Opportunity to improve quality
Potential for Partnerships with MLTC-FIDA Plans and Other Groups
Sources of Revenue and other Payment Arrangements with MCOs
o Shared Savings in Risk Models and Other Payments for meeting Quality Targets
Opportunity for Alternate Level of Care
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Characteristics of a Preferred Nursing Home Partner
Alignment of Goals
Quality Focus
Patient-Centered Care
Cost Efficiency
Excellent Customer Service
Innovative Care Delivery
Advanced Care Units
Palliative care
Strong Leadership
Supporting Infrastructure
Educated Staff
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Quality
CMS Quality Measures
Nursing Home 5 Star Ratings
Managed Care 5 Star Ratings
FIDA- Quality Measures
Evidence Based Guidelines
Diabetes, Heart Failure, COPD
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Quality Performance Metrics: What are we looking for?
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CMS Quality Measures
Hospitalization Rates
Avoidable/Unavoidable
30, 60, 90 Re-Admission Rates
Emergency Department transfers within 72 hours of SNF admission
Length of Stay for Short Term Population
Patient Satisfaction Scores
Clinical Chronic Care Measures
Ex. Management of Diabetes, HF and COPD, Hyperlipidemia
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Know Your Know Your Core
Competencies
• Review successful program and services
• Review metrics of key indicators
Leverage Your Leverage Your Core
Competencies
• Assess areas of expertise which can be utilized to service MLTC population
Think Outside The Box
• Generate new competencies for innovative clinical models that demonstrate good outcomes and improve transitions of care
Educate and Communicate
• Educate families, staff and residents about managed care
• Community Outreach
Prepare Strategically
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Financial Systems
• Know your cost by level of care • Know your capacity for risk • Good billing systems
Clinical Systems
• Disease Management • Tracking additional outcomes• Manage Transitions of Care - Care Management• Formal Clinical Reviews of Hospitalizations, Re-Admissions and Clinical measures
Physical Space
• Optimize program space• Convert long term care beds
Technology
• EMR • Transfer of prompt accurate electronic information across all settings • Enhanced discharge planning tools
Infrastructure
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INNOVATIVE CARE DELIVERY
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SNF‐ Sub‐acute3 Day Hospital Stay Required
SNF‐ Sub‐acute/Advanced Care Unit
3 Day Hospital Stay Waived
Paradigm Shift
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CURRENT MODEL
NEW MODEL
• Hospital (In‐Patient)
• Hospital EDs• Physician Groups• Urgent Care Centers• Medical Homes
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Level of Care in which medically necessary care can be provided to maintain the patient’s medical stability – The patient is at low risk for deterioration with appropriate care
An alternative acute in-patient hospitalization
An acute event as a result of an illness, injury or exacerbation of a chronic disease
Does not require extensive diagnostic or invasive procedures
Plan of Care anticipates discharge or transfer to another level of care
Medical Care and Coverage needs to mirror hospital
Evaluation upon arrival and 24/7 coverage
Advanced Care Units From the Payers Perspective
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Advanced Care Units ( cont’d)
Patient Profiles
Medically Complex and Medically Stable
Pneumonia
UTI
Dementia with Increased Agitation
Altered Mental Status
Heart Failure
Gastroenteritis/Dehydration
End Stage Organ Failure –COPD, CHF, Liver Failure
Fracture without Surgery
Palliative Care for Pain/Symptom Management
Referral Sources
Internal Transfers
Emergency Department
Community members-- Physicians, Palliative Care Programs
ACOs and Care Managers
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Advanced Care Units ( cont’d)
Design Clinical Program and Model of Care
Develop Business Plan
Define what specific services are covered
What’s included in the basic fee
What it would cost to run a high quality unit
Define Utilization Management Criteria
Identify Key Partners and Referral Sources
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Palliative Care
Comprehensive Program
Advanced Care Planning
Short-term – Long-term
Pain and symptom management, comfort care
Educational program for staff, families and physicians
Ongoing caregiver support and education
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Critical Partnerships
►Partnerships and relationships need to be developed to provide referrals
►and /or provide services.
► Hospitals
► Hospitals EDs for rapid admissions
Managed Care Organizations – Care Managers – Transitional Care Nurses
Physician Groups
Accountable Care Organizations
Health Homes
Urgent Care Centers
Ambulatory Care Centers
Diagnostic Facilities
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Q & A
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