Promising Practices: A Preliminary Report on the

LifeLong Complex Care Initiative

September 24, 20151:30 – 2:45 PM Pacific Time

The project described was supported by Grant Number 1C1CMS331054 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily

represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. These findings may or may not be consistent with or confirmed by the independent evaluation

contractor

2

Welcome – Housekeeping

• To access captioning: –For MAC users• click on Media Viewer in the lower

right hand corner–For WINDOWS users• click on Media Viewer in the upper

right hand corner

Windows Closed Captioning in Media Viewer

Closed captioning is available in Media Viewer.

You can read a transcript of the Web Forum in real time!

Windows Closed Captioning in Media Viewer

On the bottom right corner of your screen, click Show/Hide Header.

Windows Closed Captioning in Media Viewer

During the course of the presentation, another window may cause the Media Viewer to collapse.

This may happen during a Poll, for example.

Windows Closed Captioning in Media Viewer

Click this icon to bring back the Media Viewer with the closed captions.

7

Welcome – Housekeeping

• We will take questions at the end of the presentation

• Type your questions in the chat box• The webinar transcript and slides will be

available following the webinar on the DREDF website – dredf.org

8

Aging and Disability Partnership for Managed Long Term Services and Supports

• Established by the National Association of Area Agencies on Aging (N4A) as part of a project funded by the Administration for Community Living (ACL)

• Project partners:– National Disability Rights Network– Justice in Aging– Disability Rights Education and Defense Fund (DREDF)– Health Management Associates (HMA)

9

Aging and Disability Partnership for Managed Long Term Services and Supports

• Project goals:– Leverage the aging and disability networks’

extensive infrastructure, service capacity, and expertise to ensure delivery of high quality managed long-term services and support to seniors and people with disabilities

10

Webinar Series Purpose

• Purpose: To share three promising practices that feature collaborations between Independent Living Centers, ADRCs, AAAs, Medicaid managed care plans, and healthcare providers

– # 1: FREED and ADRCGrass Valley, California

– # 2: Center for Independent Living, Alameda Alliance Health Plan, LifeLong Medical Care

Berkeley, California– # 3: Access to Independence and Care1st Health Plan

San Diego, California

11

Webinar Series Goals

• Goals: To illustrate how collaborations between ILCs, ADRCs, AAAs, Medicaid managed care plans, healthcare providers, and other partners– Infuse IL philosophy and services into M/LTSS– Improve health outcomes for seniors and PWD– Increase community integration and participation

for seniors and PWD– Have the potential to generate cost savings

12

Agenda

• Vision• Project description• Peer coaches• Consumer goals• Client stories• Nurse care managers• Client stories• Preliminary outcomes/challenges/lessons

learned

13

PresentersThomas Gregory

Deputy Director

Center for Independent Living

Berkeley, California

Kathryn Stambaugh

Geriatric Services Director

LifeLong Medical Care

Berkeley, California

Silvia Yee

Senior Attorney

DREDF

Berkeley, California

Mary Lou Breslin

Senior Policy Advisor

DREDF

Berkeley, California

The LifeLong Complex Care Initiative (LCCI)

The three collaborating partners:

• LifeLong Medical Care (LifeLong), a Federally Qualified Health Center, Alameda County, California

www.lifelongmedical.org• Center for Independent Living (CIL), the ILC for northern Alameda

County, Berkeley, California www.cilberkeley.org• Alameda Alliance for Health (Alliance), an MCO serving Alameda

County, Alameda, California

www.alamedaalliance.org

VisionAn innovative partnership between an Independent Living Center and a Community Health Center to:

• Improve primary care- Nurse Care Management- On-site Peer Coaching- Services based on the Independent Living philosophy and social model of disability

• Improve health while reducing costs: - Better health outcomes- Fewer ER visits and inpatient admissions

Independent Living Philosophy

• Independent Living is living by your own rules and making your own choices about all aspects of your life• where you go• where you live• how you support yourself• how you receive health care• how you manage any help you might need

to do these things.

Independent Living Philosophy

• People with disabilities are the best experts on their lives

• They inherently have the right to make all decisions regarding any aspect of their lives, no matter their disability

• The experience of disability is largely a result of how society is organized (rather than the characteristics of an individual person)

• This idea is called the “social model of disability”

The Social Model of Disability

Cartoon Description

• Slide shows a person using a wheelchair positioned at the foot of a flight of stairs

• Text balloon on the left says, “Her impairment is the problem. They should cure her or give her prosthetics.” Below the balloon are the words, “The medical model of disability.”

• Text balloon on the right says, “The stairs are the problem. They should build a ramp.” Below the balloon are the words, “The social model of disability.”

Project Description• PC/RN teams worked at three community

health centers in Berkeley• Consumers could choose any combination of

services: – Care Management– 1-on-1 Peer Coaching, and/or– Living Well workshops

• Both roles helped consumers recognize and reinforce their strengths, learn new skills, and make independent decisions

Project Description

• Generally the RN addressed medical concerns and the PC worked on all other concerns, but there was a great deal of overlap

• 227 people enrolled over 2.5 years (of these, 106 received Peer Coaching, 200 received nursing, and 79 received both)

• Staff included 3 FTE RN Care Managers and 1.5 FTE Peer Coaches

Target Population• Members of Alameda Alliance (generally with

an aging or disability-related Medicaid aid code)

• Risk Score > 1.2 (using the Johns Hopkins ACG System)

• Identified by health center staff as likely to benefit from Peer Coaching or RN Care Management

• Interested in participating (most important!)

Consumer Profile

• Age range 22-91 (64% were under 65 and 36% were 65 or over)

• Race: African American (47%), White (28%), Asian or Pacific Islander (3%), other (15%), Unknown (7%)

• Ethnicity: Latino/a (12%)• 63% female; 37 % male• 80% of enrolled consumers had a behavioral health

diagnosis, especially anxiety (50%) , depression (66%), and/or substance abuse (29%)

• 76% had Hypertension; 59% had Diabetes• 6% identified as homeless (many more had unstable

housing).

Financing

• Health Care Innovation Award:- 3-year cooperative agreement (July 2012 – June 2015) with Centers for Medicare & Medicaid Services.

- Paid for Nurse Care Managers, some Peer Coaching, staff training, consumer transportation, program supplies, and administrative coordination.

• Alameda Alliance for Health:- Local non-profit Medicaid managed care plan- Paid for Peer Coaching & Living Well workshops

Peer Coaches

• Hired and trained by CIL; worked at LifeLong’s health centers and at CIL.

• Provided 1-on-1 support to identify goals and develop and implement concrete plans for pursuing those goals; also provided information and referral, peer counseling, and skills instruction as needed.

• Facilitated 8-10 week series of health-n-wellness workshops called Living Well (certified by the University of Montana's Rural Institute). Offered about 4-6 series per year (some in English, some in Spanish).

• Worked with about 12 consumers at a time (full-time peer coach).

What is a “Peer”?

• People with disabilities (not necessarily the same disability as the consumer)

• Not medical professionals • Sometimes shared other characteristics with

consumers (age, race, gender) but often didn’t• Main qualifications: understanding of the IL

Philosophy; knowledge of local resources & systems; skills to support people to do more for themselves; positive, “can do” attitude.

Summary of Consumer Goals

• Community Resources (88% of consumers)• Getting & Keeping Housing (56%)• Healthcare Access & Issues (31%)• Motivation Building (26%)• Financial Education (23%)• Self-Advocacy (20%)

Consumer Feedback

• Consumers told us that working with a peer coach has helped them:– Build confidence– Set goals– Access information – Find resources like food and housing– Complete paperwork

Example 1

Ms. L is a 70 year-old woman with cognitive difficulties following a traumatic brain injury. She also faced multiple other health challenges, including hypertension, depression, anxiety, stroke and cancer. At the time she signed up for Peer Coaching, she was homeless.

Example 1 (cont’d)

She participated in Living Well classes during her transition to permanent housing, and reported that peer support helped her learn to advocate for her needs. Now, she feels more secure and less isolated and ashamed, and she is better able to manage her chronic medical conditions.

Example 2

Ms. W is a 63 year-old woman living with several chronic medical conditions, including asthma, hypertension, pre-diabetes, sleep apnea. She also has agoraphobia and depression. During a three month period, she worked with a nurse care manager on her medical concerns and Peer Coach on other “life” concerns. During this time, Ms. W’s blood pressure and depression scores improved, and she became much more activated to self-manage her medical conditions.

Example 2: Successes

[Ms. W] recognizes her successes and she feels more empowered. Within three months she overcame significant anxiety and achieved a lot: • Applied for and received In Home Supportive

Services (IHSS)• Hired a caregiver• Advocated for herself with her insurance • Decided to attend Living Well workshops

Example 2: Successes

• Cleaned clutter at her house • Researched and selected a phone vendor • Established open communication with the RN

at the clinic; now calls her before she goes to the ER

• Feels more in control of her decisions

Peer Coaches “in action” at a Health Center

and at CIL’s offices

Photo Descriptions

• Two photos are shown• Photo at top left shows a Latina with dark hair

wearing a blue sleeveless dress seated at a desk talking with a woman in her late 50’s who is wearing a pink sweater and who is seated beside the desk.

• Photo at the right shows a seated African American man wearing a yellow sweater talking with a seated Asian woman with gray hair and glasses. Both are looking at some papers together.

Nurse Care Managers• Offered care coordination, systems navigation,

advocacy, medication reconciliation, triage of acute concerns, chronic disease management, health education, and assistance with social challenges such as housing and transportation

• Visited with consumers in the health center and home

• Served as the main referral source for the Peer Coach

• Worked with about 30 consumers at a time

Example 1

Mr. P is a 50 year-old man with major complications from diabetes who was referred to a Nurse Care Manager following a 7-day hospital stay. The RN helped with:• Transportation for medical appointments• Missing lab results and prescriptions• Missing records

Example 1, continued

Mr. P described the RN Care Manager as follows: “[He] was there through the worst of not being able to cope. He listened to my priorities. He has been up to bat for me on countless occasions. Less so now … I’ve become more functional, so he is not involved as much precisely because he’s already helped me. … I have managed to turn my health around to a large extent.”

As Mr. P’s health improved, he began working with a Peer Coach on other life goals, including employment.

Example 2

A 57 year-old man with multiple medical and behavioral health issues, Mr. G first began working with a RN Care Manager on a variety of medical concerns. Then, a housing crisis took priority. Facing eviction, Mr. G worked with his Care Manager to complete 16 housing applications and research emergency shelters. With the help of his nurse and his sister, Mr. G found housing in Berkeley the day before he would have become homeless.

Example 2, continued

Housing crisis averted, Mr. G was able to continue working on medical issues with his nurse and also began pursuing other goals, such as learning to read and navigate public transportation, with a Peer Coach.

Example 2, continued:

Mr. G says he now feels better equipped to deal with his challenges because “I’m surrounded by people who want to help me and that’s good. It gave me a whole new outlook on life …. I’m thinking a whole lot better and clearer.” He reports that he now gets his medications on time, makes it to most medical appointments, and has reduced his ER use from 2-3 visits per year to none in 2015.

Photo Description

• Photo shows an older white man who is using a motorized wheelchair that is positioned next to a young white woman with long brown hair and wearing a green shirt. She is seated on a stool and is taking the man’s blood pressure

Preliminary Outcomes*

• More than half of PC consumers achieved at least one ILP goal.

• 70% of consumers interviewed reported either an emotional improvement (optimism, empowerment, wellbeing) or a health improvement. 30% percent reported both.

*The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

Preliminary Outcomes*• 28% improvement in PHQ-9 depression scores

(significant at p ≤ 0.01)• Average improvement in PAM score of 8.44

points among consumers with 10+ visits (significant at p ≤ 0.01)

• 91% of consumers showed an increase in their total health literacy score or maintained a positive response of “almost always” or “always.”

*The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

Preliminary Outcomes: Cost Savings*

• Consumers showed a reduction in ED visits (from 368 to 286), inpatient days (from 117 to 75), and Skilled Nursing days (from 208 to 79).

• Reduction in ED visits was statistically significant at p<.05; Inpatient and SNF data were not significant (further analysis with a larger sample is planned)

• Estimated cost savings: $330,000 (estimated using average cost data for ED, inpatient, and skilled nursing services).

• Independent evaluation of outcomes and cost savings is being conducted by NORC, affiliated with the University of Chicago (http://www.norc.org)

*The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

Challenges…

In addition to the fundamental challenge of working with consumers to support them in achieving their goals, there were some challenges that resulted from the structure of the LCCI collaboration

Practical/Logistical Challenges:

• Peer Coaches were working mostly off CIL premises–no onsite supervisor–no CIL colleagues onsite

Practical/Logistical Challenges (cont’d):

• Lots of travel time– travel between clinics for the full-time Peer Coach– travel between clinic(s) and CIL for both Peer

Coaches– travel between clinic and CIL in the case of Care

Managers and administrative leads

• Double training required– Peer Coaches needed to be trained in CIL's protocols

and systems and LifeLong's protocols and systems

Practical/Logistical Challenges (cont’d):

• Limited control over workflow– Peer Coaches couldn't really conduct outreach to

recruit new consumers as the pool of eligible consumers was so rigidly defined

– Peer Coaches relied on Care Managers to function as the Peer Coaches' "marketing departments" and provide referrals

• Abiding by HIPAA when communicating inter-agency

Philosophical Challenges:

• Peer Coaches' priorities were– "do with, not for”– consumer self-direction and

participation– consumer choice

• Care Managers’ and other clinicians’ priorities–physical health and wellness.

Philosophical Challenges (cont’d):

• Finding the optimal degree of "integration”– The Peer Coach and the Care Manager were

meant to work closely in tandem– Issue: ”If the Peer Coach is privy to all the

consumer's medical info, the Peer Coach seems less and less like a peer and more and more like an adjunct clinician."

Authorizations & Billing

• Administrative challenges–billing Alameda Alliance–tracking and renewing authorizations,

which automatically expired in three months whether or not the hours authorized had been exhausted

Authorizations & Billing (cont’d)

• Peer coaches struggled to maintain a high ratio of billable time to unbillable time– necessary if this project is to be financially viable

in the absence of the CMS HCIA funding• Project full-time Peer Coach hovered around

50% billable time• Part-time Peer Coach hovered around 30%

billable time

Lessons learned:

• CIL staff imparted to LifeLong staff a greater understanding of and appreciation for IL Philosophy

• CIL staff also came to better understand factors that caused medical professionals to sometimes move forward with services without waiting for the consumer to self-direct

• While collaboration between partnering agencies is a great way to leverage resources, inter-agency coordination inevitably leads to complications (e.g., staff turnover at one agency impacts the work of staff at the other agency).

Lessons Learned:

• Take time, at the beginning of the partnership, to bring health center staff and ILC staff together for a thorough orientation to the work, philosophy, and history of the other organization.

• Hold regular in-person meetings to for project staff to discuss successes and challenges.

Lessons Learned:

• Social Determinants of Health!

When asked to describe the most important assistance provided by a Peer Coach or RN Care Manager, many patients shared stories about housing, unemployment, and other needs.

Lessons Learned:

• To benefit from Peer Coaching, consumers must– be able to understand the consequences of their

choices– be close to ready to make changes

• A good Peer Coach can assess readiness for change

• Consumers facing acute medical issues are less likely to benefit from Peer Coaching until their acute issues are stabilized

Lessons Learned:

• RN Care Management is helpful when:– Medical needs are not being met – The consumer requires a specific nursing service,

such as health education, assessment of symptoms or fall risk, or medication reconciliation

– A home visit is warranted, or– A consumer’s bio-psychosocial situation is

complex

Lessons Learned:• The LCCI:– demonstrated the value of the community health

center and Independent Living Center partnership– highlighted the importance of intensive services

for consumers facing complex health and psychosocial issues

• Key to the success of the partnership – respect for the consumer as the key decision

maker in their healthcare– equal emphasis on social as well as medical

factors critical to wellness

The project described was supported by Grant Number 1C1CMS331054 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. These findings may or may not be consistent with or confirmed by the independent evaluation contractor.

Thank You from the LCCI team!

Photo Description

• Photo shows nine people standing in a row posing for a staff photo in front of a brown backdrop

• Three men are shown• Six women are shown

Questions?

Please take this opportunity to type your questions in to the CHAT box while we bring up a few of the questions that have been asked so far.

Alameda County

• Mandatory Medicaid managed care since 2011-2012

• Choice of two managed care organizations (MCOs)

• Not currently a managed long-term services and support county (MLTSS)

• CA has instituted MLTSS in 7 of the state’s most populated counties

Proposed Medicaid Managed Care Rule

• On July 1, CMS proposed its first major revision of Medicaid managed care since 2002

• Medicaid has grown, MCO delivery of Medicaid has substantially grown, and there is now significant MLTSS across the country

• The proposed rule attempts to regulate this new landscape

• Not final – 60 day comment period closed

Rule - MLTSS Principles

• The proposed rule incorporates existing 2013 Guidance from CMS that set out 10 MLTSS “Principles,” including the enhanced provision of home and community-based services in accordance with the Supreme Court’s Olmstead decision, and person-centered needs assessment and service planning

• 1st time definition of MLTSS – quite broad

Rule - Care Coordination

§ 438.208(b)(2) expands MCO coordination obligations by requiring:• Coordination between care settings and with

services provided outside of the MCO, including fee-for-service Medicaid benefits such as LTSS

• Potentially may set an additional standard to require community or social support services

Rule - Network Adequacy

• For the first time, the rule requires states to develop standards on the adequacy of Medicaid MCO provider networks, including LTSS providers when part of the MCO network (§ 438.68 (2))

• Currently time and distance standards when consumers travel to the LTSS provider, and other kinds of standards when LTSS providers travel to the consumer

• It is unclear how ADRC services would be categorized, or when they would be “sufficient”

• LTSS subcontractors – accountability and data

Rule - LTSS Provider Credentialing

• The proposed rule newly establishes a “credentialing” and “recredentialing requirement for the providers that enter MCO contracts or participation agreements, including LTSS, behavioral, and substance use disorder providers

• Big potential impact on community-based LTSS providers who work with Medicaid beneficiaries now and want to do so under managed care

71

Thank you!• More questions?• Contact:– Kathryn Stambaugh – kstambaugh@lifelongmedical.org– Thomas Gregory – tgregory@cilberkeley.org– Mary Lou Breslin – mlbreslin@dredf.org– Silvia Yee – syee@dredf.org

• For more information, visit:DREDF www.dredf.org Aging and Disability Partnership http://mltssnetwork.org/