CCC Provider Training Summary Virginia Premier Health Plan.

CCC Provider Training SummaryVirginia Premier Health Plan

Virginia Commonwealth University Health System Health Plan Division

2

Table Of Contents• Overview 4

• Disability Literacy: Mental Health Awareness 5– Course Summary 6

• Introduction 7• Identifying Patients 8

• Working with Patients 9• Crisis Intervention 11• Services and Resources 13• Long Term Support and Services (LTSS) 14• Additional Services and Resources 16• Assessing Needs 17• Integration 18

• Disability Literacy: Access, Accommodations and The ADA 19– Course Summary

• Providing Healthcare 20• The ADA & Olmstead 21• Prejudices & Myths 22• Providing Healthcare 23• Providing Care/Literacy 24• Providing Care/ Language 25• Providing Care/ Chronic Conditions 26


3

Table Of Contents• Access 27• Barriers 29• Accommodation 30• Conclusion 31

• Health Literacy: Caring For Our Members & Patients 32– Course Summary

• Wellness Principles 33• Person Centered Planning 36• Independent Living 38

• Model of Care 40– Course Summary 41

• Cultural & Disability Sensitivity 43• Fraud & Abuse 47

• Appendix 51• Appendix Introduction 52


4

Overview

This module includes course summaries for the Commonwealth Coordinated Care Provider Training. • Disability Literacy: Mental Health Awareness• Disability Literacy: Access, Accommodations and the ADA• Health Literacy: Caring For Our Members and Patients• Model of Care*

*This course is specific to VA Premier Health Plan, Inc.

Disability Literacy: Mental Health Awareness


6


Course Summary

The National Alliance on Mental Illness defines a mental health impairment as: A medical condition that disrupts a person's thinking, feeling, mood, ability to relate to

others, and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a diminished capacity for coping with the ordinary demands of life.

Data indicates that individuals with intellectual development disabilities (IDD) or mental health issues are more likely to live at home, are often part of the dually eligible program, much more likely to use emergency services and are often the last and least served.

“These crises are not the inevitable consequences of mental disability, rather, they represent the combined impact of additional factors, such as lack of access to essential services and supports, poverty, unstable housing, coexisting substance use, other health problems, discrimination, and victimization.”

Paolo del Vecchio, M.S.W., Associate Director for Consumer Affairs at SAMHSA’s Center for Mental Health Services


7


Course Summary: Introduction

The Institute of Medicine recommends that providers of medical services establish “effective linkages” within their own organizations and between the providers of mental health and substance abuse.

The lack of coordination among primary care doctors, hospital emergency rooms, behavioral health practitioners, and other providers leaves patients (often with many other social challenges such as homelessness) confused, frustrated, and, too often with inadequate care.

Primary care physicians and mental health providers alike are often unaware of who is prescribing what to whom.


8


Course Summary: Identifying Patients

VPHP Medical Management staff will identify the most vulnerable patients upon enrollment and on an ongoing monthly basis.

Identifying specific information regarding the patient is also important. The DMAS medical transition data reports are used to identify patients with: Selected diagnoses Prior authorizations for services that are presently being received by individuals

who are new to the plan Patients designated as part of the vulnerable subpopulations Patients receiving services at a Community Services Board or who are assigned a

Targeted Case Manager

Members of the vulnerable subpopulation are those who struggle with behavioral and/or multiple chronic conditions.


9


Course Summary: Working with Patients

Virginia Premier staff, providers and agencies must work together to provide the key services listed here.

Service planning and coordination Cross systems/ Interdisciplinary training Outpatient mental health Residential housing/day/vocational opportunities Respite Inpatient hospitalization Behavioral support planning Family support and education/outreach


10


Course Summary: Working with Patients

The Interdisciplinary Care Team (ICT) is a member centered group that discusses the care plan, health status and current/possible interventions for the patient. The ICT is always comprised of:

The Patient The Care Manager The Primary Care Physician

Based on the needs of the patient, additional ICT members may be added:

Family members and/or caregiver or legal representation Medical and Pharmacy Directors Specialists Disease Manager Social and Medical Outreach Workers Health Educator


11


Course Summary: Crisis Intervention

When working with the mental and behavioral health population it becomes criticalthat members of the ICT have an understanding of Crisis Intervention and Prevention.

Crisis prevention should come through early identification of individuals at highrisk. The immediate involvement of the ICT in the development of a crisis response plan is critical.

Reaching out to community agencies that specialize in crisis prevention tactics and education should almost always be part of the intervention plan. In addition, providing assistance and education to family members/caregiver or guardian in crisis situations is essential as they may be feeling a higher level of crisis/stress than the patient.

Should a patient present with signs of a crisis or potential crisis: Call the Community Service Board (CSB). CSB will send someone to complete a crisis assessment on the patient. If the crisis staff representative feels the patient is a danger to him/her self or someone else,

they can obtain a temporary detention order (TDO).


12


Course Summary: Crisis Intervention

When working with patients with mental health issues, particularly those who have experienced a crisis, understanding the concept of recovery is key.

For many people, the concept of recovery is about staying in control of their life despite experiencing a mental health problem. Professionals in the mental health sector often refer to the ‘recovery model’ to describe this way of thinking.

Putting recovery into action means focusing care on supporting recovery and building the resilience of people with mental health problems, not just on treating or managing their symptoms.

There is no single definition of the concept of recovery for people with mental health problems, but the guiding principle is hope – the belief that it is possible for someone to regain a meaningful life, despite serious mental illness. Recovery is often referred to as a process, outlook, vision, conceptual framework or guiding principle.


13


Course Summary: Services and Resources

This session provided information regarding agencies, services and resources available to the mental and behavioral health population. This summary provides a look at just a few.

Respite care (agency and consumer-directed) is a service provided tounpaid caregivers of patients who use Waiver services. Respite is provided on an episodic or routine basis because of the absence of or need for relief of those unpaid individuals who normally provide the care.

Therapeutic consultation is provided in fields such as psychology, social work, behavioral analysis, speech therapy, occupational therapy, therapeutic recreation, physical therapy disciplines or behavior consultation to assist patients with disabilities, parents and family members, and providers to implement goals and services.


14


Course Summary: LTSS

LTSS includes: Adult Day Health Care (ADHC) Services Personal Care Services: by Agency and Consumer-Directed Personal Emergency Response System (PERS)

With or without medication monitoring Respite Care Services – Agency and Consumer-Directed Transition Services and Transition Coordination Assisted Living or Nursing Home


15


Course Summary: LTSS

Long-Term Support and Services (LTSS): A variety of services that assist individuals with health or personal needs of daily living over a period of time. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities.

Long-term services and supports can be provided at home, in the community, or in various types of facilities, including NFs and assisted living facilities.


16


Course Summary: Services and Resources

Additional services and resources include:

Behavioral Therapy Services

Community Mental Health Rehabilitative

Services (CMHRS) (such as Intensive In Home, Therapeutic Day Treatment, and Mental Health Supports for adults)

Targeted Case Management

Treatment Foster Care Case Management

Residential Treatment (Levels A, B & C)

Substance Abuse Services

Inpatient and Outpatient Psychiatric and Substance Abuse Treatment Services (such as medication management, and individual, family, and group therapies) for non-MCO enrolled individuals


17


Course Summary: Assessing Needs

Each member of the health plan will have a primary care provider, a care manager, and an interdisciplinary care team who will serve to identify new issues that the member may be experiencing and communicate these to other members of the team.

VPHP will also ensure that members are re-assessed on a periodic basis to identify new issues that have arisen. VPHP will utilize its predictive modeling tool in order to identify individuals who have recently experienced a change in condition to predict which members are at-risk for an adverse medical event and require intervention.


18


Course Summary: Integration

Behavioral health must be fully integrated in the delivery or physical health and LTSS services to be effective. A full integration in addressing the behavioral health needs of the patient benefits the individual and the system in general promoting efficiencies and alleviating administrative burdens.

An integrated Medicare/Medicaid system will also benefit healthcare providers who, like dually eligible members, face the challenges and confusion of navigating an otherwise fragmented system. Promoting efficiencies and alleviating administrative burdens for providers is critical to maintaining adequate networks and access to care.

Disability Literacy: Access, Accommodations and The ADA


20

Disability Literacy: Access, Accommodationsand The ADA

Course Summary: The ADA & Olmstead

In Olmstead vs. L.C., the Supreme Court ruled that disabled people have “the right to receive care in the most integrated setting appropriate and that their unnecessary institutionalization was discriminatory and violated the ADA.” This ruling created several home and community based services (HCBS) programs and started a transition movement.

Transition involves the transfer of individuals from skilled nursing facilities (SNF) to a HCBS location and requires the SNF and the local contact agency (LCA) to investigate and resolve resident complaints about: movement into the community, supporting residents in their decision-making to leave a SNF, providing residents information and education about their rights and

options, and identifying appropriate candidates and making the necessary referrals to

LCAs.


21


Course Summary: Prejudices & Myths

When addressing the provision of effective health care for patients with disabilities, the place to begin is by taking a look at personal prejudices – discovering and mitigating filters, myths and assumptions. Prejudices and myths create barriers in understanding, communication, and improved health care. Challenge your first impressions when first meeting a disabled patient.

MYTHS: People with disabilities live very different lives than people without disabilities. A person’s disability defines who they are as an individual. People with disabilities are sick and in constant pain.

Prejudices and assumptions may also be made when a person presents with a disability that is misunderstood. For example, people with speech impediments are often thought to cognitive disability or mental illness.


22


Course Summary: Providing Health Care

The reason this chapter is so important is because patients with disabilities or limited English proficiency often perceive that their physicians do not listen to them, explain treatment options, treat them with respect, spend enough time with them, and/or involve them in the treatment decisions.

Part of the disconnect stems from a lack of understanding on how to communicate with individuals with certain disabilities and what auxiliary aids are available to improve communication.

The law requires that a public accommodation must provide auxiliary aids and services when they are necessary to ensure effective communication with individuals with hearing, vision, or speech impairments.

"Auxiliary aids" include such services or devices as qualified interpreters, assistive listening headsets, television captioning and decoders, telecommunications devices for deaf persons (TDD's), videotext displays, readers, taped texts, Braille materials, and large print materials.


23


Course Summary: Providing Care/Literacy The following populations are at high risk for limited literacy and/or competency skills. Many patients in these

groups have well-developed skills; however, others struggle with health literacy. It is critical to their health care that their physicians uncover and address their needs.

Elderly Low-income English as a second language Deaf or hard of hearing People with learning disabilities Individuals who did not graduate from high school Recent immigrants Individuals with unique health challenges

Tools that can help determine literacy levels include but are not limited to: ABLE: Adult Basic Learning Examination LAD: Literacy Assessment for Diabetes NLS: Nutritional Literacy Scale REALM: Rapid Assessment of Adult Literacy in Medicine TOFHLA: Test of Functional Health Literacy in Adults


24


Course Summary: Providing Care/Language Medicaid regulations require that the primary language spoken by each individual be identified at the time of enrollment and that each managed care member be provided with the names of contracted providers that speak languages other than English in the patient’s service area. Additionally, Medicaid regulations require states to make oral interpretation services available and require that each MCO make these services available free of charge to each patient and potential patient.

In all cases, MCOs are required to consider the needs of patients who may requirealternative methods of communication, such as patients with visual impairments, and provide communication services necessary to accommodate these patients. MCOs must provide communication materials in all of the prevalent languages within the MCO’s service areas. Plans that cover service areas with a significant non-English-speaking population are required to provide written patient materials in the language of these populations.

The Rehabilitation Act Title 508 states that individuals with disabilities must have access to and use of information and data that is available to patients of the public who are not disabled.


25


Course Summary: Providing Care/Chronic Conditions

One critical piece of information regarding providing health care to patients with disabilities is understanding the risk among the disabled population to suffer from chronic conditions. As a provider, it is important to understand that the risk of suffering from multiple chronic conditions is much higher among patients with disabilities.

Elderly or Disabled with the Consumer Direction waiver Intellectual/developmental disabilities Cognitive or memory problems Physical or sensory disabilities Residing in nursing facilities Serious and persistent mental illnesses End stage renal disease Complex or multiple chronic conditions Anticipated long-term service and support needs in the future


26


Course Summary: Access

In order to function effectively and safely in jobs, education, and everyday life, people with disabilities have to have physical and social access to the same spaces, employment, goods, services, entertainment, and community participation that everyone else does. When that’s the case, their disabilities don’t limit their ability to fully participate in life.

This session provided information regarding access to communication, information, programs and services and suggested means of providing access through technology: Readers Internet TTY and TDD equipment


27


Course Summary: Access

The ADA requires businesses and other public facilities to allow service animals to accompany people with disabilities on their premises, and forbids excluding people with service animals or isolating them from other customers. Making this type of accommodation for individuals builds confidence, increase self-sufficiency and integration into the community.

Once members with special health care needs are identified, Medicaid regulations require that MCOs conduct an assessment of each special needs member to identify conditions that require regular treatment and monitoring, and provide these members with programs, processes, and accommodations that enable patients to have access to health care providers who specialize in that condition.


28


Course Summary: Barriers

In this session, a multitude of barriers were discussed including:

Attitude

Lack of Services

Ineffective Communication

Language

Emotional issues and lack of confidence

Also discussed were barriers and regulations surrounding physical access. Under the ADA, it is expected that the government body, the owner or tenant of the space, the service provider, the employer, etc. make a “reasonable accommodation” to enable access for people with disabilities. A reasonable accommodation is an adjustment to whatever barrier prevents access that doesn’t impose an undue hardship on the individual, business, organization, or institution providing the accommodation, or on its other users or participants.

Ways in which to make these accommodations were explored in this chapter.


29


Course Summary: Accommodations

Another aspect of accommodations is providing a disabled individual with options for independent living.

Consumer direction ranges from the individual independently making all decisions and managing services directly, to an individual using a representative to manage needed services.

Individuals have the primary authority to make choices that work best for them, regardless of the nature or extent of their disability or the source of payment for services.

Existing models vary; however, all models of consumer direction reflect three central beliefs:

1. People with disabilities have a unique understanding of their personal care needs.

2. Many patients are competent to oversee the delivery of personal care and services.

3. Service recipients – rather than service providers – have a right to control the personal care services that significantly affect their day-to-day existence.


30


Course Summary: Conclusion

Challenge your perceptions, prejudices and commonly held myths Familiarize yourself with the populations most often impacted by the stigma

of “disabled” Use tools and techniques to identify literacy – not assumptions and

preconceived generalities Fine tune your key communication skills Audit your office and your staff against the barriers introduced in this

session and remove as many as possible Talk to patients about their perceptions of communication and treatment in

order to continually improve your approach

Health Literacy: Caring For Our Members & Patients


32

Health Literacy: Caring For Our Members &Patients

Course Summary: Wellness Principles

Wellness principles revolve around a holistic philosophy and active lifestyle that helps members achieve their maximum health potential. Therefore the principle of wellness is focusing on the mind and body. Wellness principles focus on a medical approach that doesn’t wait for someone to show signs of illness before taking action.

Virginia Premier’s medical management staff partners with members to achieve a positive impact on their wellness through educational opportunities, screenings, and programs that are geared toward helping members improve and then maintain their health. Initiatives include but are not limited to: Annual influenza and pneumococcal vaccines Preventative services for the management of chronic conditions One-on-one counseling


33



Primary Care Physicians and Specialists (as needed) will be a part of each member’s Interdisciplinary Care Team. The care manager, member and physician will work together to develop an individualized wellness plan for each enrollee. However, in order for members to achieve the best possible outcomes, they need to understand their responsibility in taking charge of and participating in their own personal wellness.

Virginia Premier’s goals center around continuous improvement in each area of member wellness, with the ultimate goal of helping members reach their maximum health potential. Improvements include but are not limited to:

Improving access to essential services and affordable care Improving coordination of care through an identified point of contact Improving seamless transitions of care across healthcare settings Improving access to preventative health services and assuring

appropriate utilization of services


34



Person-centered planning is a process directed by the family or the individual and is intended to identify the strengths, capacities, preferences, needs and desired outcomes of the individual.

The goal is to have the needs directed by the member or by the family. if appropriate. Goal setting is primarily the responsibility of the member.

Participants in the person-centered planning process can utilize a mix of paid and non-paid services and supports that will assist them achieve personally-defined outcomes.

Virginia Premier care managers will work with members and their Interdisciplinary Care Team to create, review and update a Plan of Care.


35


Course Summary: Person-Centered Planning

Person-centered planning is a process directed by the family or the individual and is intended to identify the strengths, capacities, preferences, needs and desired outcomes of the individual.

The goal is to have the needs directed by the member or by the family. if appropriate. Goal setting is primarily the responsibility of the member.

Participants in the person-centered planning process can utilize a mix of paid and non-paid services and supports that will assist them achieve personally-defined outcomes.

Virginia Premier care managers will work with members and their Interdisciplinary Care Team to create, review and update a Plan of Care.


36


Course Summary: Person-Centered Planning

The care manager will include input from the ICT to create the plan and serve as a single point of contact for the member.

The Plan of Care should be based on health outcomes important to the member, and all plans are to be both comprehensive and holistic.

An important aspect of person-centered planning is the concept of a community presence in the member’s life. Other important concepts include self-direction and a focus on the member’s talents and gifts.

Person-centered planning is not a one-time event. It is an ongoing activity requiring caregivers to listen, learn and lend support to the member while he/she is on this journey.


37


Course Summary: Independent Living

Independent living is the belief that each person with a disability is unique, has the same civil rights as people without disabilities, and should have equal access to social and economic services.

Care should be person-centered and support self-direction. Therefore, the philosophy centers around working with individuals with disabilities so that they may maintain or take back charge of their own lives and make their own choices.

The independent living philosophy believes that individuals with disabilities know their needs best and have the right to determine how they integrate into the community.


38


Course Summary: Independent Living

Centers for Independent Living (CILs) are non-residential, non-profit facilities that help support this philosophy through a variety of services.

CILs provide services for individuals with varying degrees of disability including those with significant disabilities and/or challenges.

Services provided include but are not necessarily limited to: Independent living skills Peer to Peer mentoring Financial, Accessibility, and Waiver services Self-determination

Model Of Care


40

Model Of Care

Course Summary

A Model of Care creates the foundation for providing the best possible care for the dually eligible population which includes individuals with:• Intellectual and/or developmental disabilities• Physical or sensory disabilities• Serious and/or persistent mental illness• Anticipated long-term support needs.

Within this session we introduced Member Rights. Four key rights the Model of Care protects include: • Timely access to a provider• Treatment with quality, respect and dignity, • Not to be treated against their will and • Have prescriptions filled in a reasonable period of time.


41

Model Of Care

Course Summary

Through the Model of Care, goals for the dually eligible population include:

• Access to essential services • Access to affordable care• Coordination of care through an identified point of contact• Seamless transitions of care across healthcare settings • Access to preventive health care services • Assuring appropriate utilization of services


42

Model Of Care

Course Summary: Cultural & Disability Sensitivity

Understanding and delivering effective health communication is the charge of all health care professionals. Effective communication can lead to positive health outcomes, such as better use of the health care system, better medical outcomes, and improved patient-provider relationships.

Cultural competence is the understanding of those values, beliefs, and needs that are associated with member's age, gender identity, sexual orientation, and/or racial/ethnic heritage, or religious background. Disability competence is the understanding of the disability, attitudes, barriers, abilities, and mental and physical challenges faced by this population.

Competence also includes a set of skills required to ensure appropriate, sensitive health care to persons of varying cultures and beliefs and/or with congenital or acquired disabilities.


43

Model Of Care


Culture is central to health care. A person’s culture can affect: • How health care information is received• How rights are exercised • What is considered to be a health problem • How symptoms and concerns about the problem are expressed • How they view and therefore follow instructions • And the relationship boundaries deemed appropriate

• Effective communication in health care can only occur with a unified approach that takes into consideration health care literacy, culture & disability sensitivity, and English proficiency.

• A unified approach looks at communication from a member-centered perspective. A member-centered perspective reflects the realities of people’s everyday lives and their current practices, attitudes, beliefs, and lifestyles.


44

Model Of Care


Health Plan literacy refers to an individual’s ability to read and understand medical or health plan text and to follow instructions. Someone with low health literacy may have difficulty navigating the health care system, sharing health information, participating in managing his/her health care.

The third component of a unified approach to cultural sensitivity is English proficiency. Limited English Proficiency (LEP) is defined as a limited ability to read, write, speak or understand English. When members have trouble communicating, the consequences can result in mistrust, dissatisfaction, medical errors and changing plans.

Reducing health care disparity requires workforce training and development, linguistic competency, and improving quality of care.


45

Model Of Care


When members have trouble communicating with health care providers, the consequences can result in a)mistrust, b)dissatisfaction, and c)medical errors.

Finally the most important component of cultural & disability competency is recognizing and acknowledging your own biases.

Be sure to examine personal biases, prejudices and filters. Talk with your

staff about the importance of never making assumptions based on someone’s appearance, cultural background, English proficiency or perceived abilities or disabilities.


46

Model Of Care

Course Summary: Fraud & Abuse

The laws surrounding Fraud, Waste & Abuse include: False Claims Act (FCA) Anti-Kickback Statute Physician Self-Referral Law (Stark Law) Social Security Act U.S. Criminal Code

Government agencies enforce these laws, including the… Department of Justice (DOJ) Department of Health & Human Services Office of Inspector General (OIG) Centers for Medicare & Medicaid Services (CMS)


47

Model Of Care


The False Claims Act protects the federal government from being overcharged or sold substandard goods or services.

The Anti-kickback Statute makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a Federal health care program.

Violation of these laws may result in nonpayment of claims, Civil Monetary Penalties, exclusion from the Medicare program, and criminal and civil liability.


48

Model Of Care


The OIG is required to impose exclusions from participation in all Federal health care programs on health care providers and suppliers who have been convicted of:

Medicare fraud Patient abuse or neglect Felony convictions for other health care-related fraud, theft, or other financial misconduct; or Felony convictions for unlawful manufacture, distribution,

prescription, or dispensing of controlled substances.


49

Model Of Care


Keeping clear documentation is important! Claims submitted should be supported by documentation. Good documentation practice helps ensure that your patients receive appropriate care from you and other medical providers who may rely on your records.

When submitting Medicare claims, you are filing a claim with the Federal Government. This session provided examples of improper claims billing practices along with the rules of balanced billing. If you have questions about these rules, review the Fraud & Abuse chapter. Also, remember that when billing Medicaid, federal guidelines always take precedent over state guidelines.

The Affordable Care Act requires drug, device, and biologic companies to publically report nearly all gifts or payments they make to physicians in 2013.

CCC Provider Training Summary Virginia Premier Health Plan.

Documents

Transcript of CCC Provider Training Summary Virginia Premier Health Plan.