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July 21, 2015

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Targeting Interventions for the Highest-Need, Highest-Cost Medicare-Medicaid Enrollees:

Health Plan Approaches

Promoting Integrated Care for Dual Eligibles (PRIDE) is supported by The Commonwealth Fund.

Questions?

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Answers to questions that cannot be addressed due to time constraints will be shared after the webinar.

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About the Center for Health Care Strategies

A non-profit health

policy center

dedicated to

improving the

health of low-

income Americans

I. Welcome and Introductions

II. Identifying High-Need, High-Cost Medicare-Medicaid Enrollees through Predictive Modeling for Targeting Services and Interventions

III. Questions and Discussion

IV. Targeting Housing and Supportive Services to Promote Community Living and Independence

V. Questions and Discussion

Agenda

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Medicare-Medicaid Enrollees are a High-Need Population

65 AND OVER UNDER 65

• More likely to have been diagnosed with 3+ chronic conditions

• 25% have a behavioral health disorder• Enrollment increased 8% since 2006

• 40% have a behavioral health disorder• Enrollment increased 20% since 2006

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• 10.7 million Medicare-Medicaid enrollees

• 1 in 5 Medicare enrollees are dually eligible

• More likely than Medicare- or Medicaid-only enrollees to have multiple, chronic health conditions

• More than 40% use LTSS

• 33% are under 65

Sources: Medicare-Medicaid Coordination Office. February 2014. Data Analysis Brief Medicare-Medicaid Dual Enrollment from 2006 through 2013; and Congressional Budget Office. June 2013. Dual-Eligible Beneficiaries of Medicare and Medicaid: Characteristics, Health Care Spending, and Evolving Policies .

Promoting Integrated Care for Dual Eligibles (PRIDE)

• Supported by The Commonwealth Fund

• Brings together seven health care organizations to identify and test innovative strategies that enhance and integrate care for Medicare-Medicaid enrollees

• PRIDE participants:

- CareSource (OH) - Together4Health (IL)

- Commonwealth Care Alliance (MA) - UCare (MN)

- Health Plan of San Mateo (CA) - VNSNY CHOICE (NY)

- iCare (WI)

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Introductions

Brianna Ensslin Program OfficerCenter for Health Care Strategies

Amanda HarcusLead Financial Data AnalystIndependent Care Health Plan (iCare)

Lisa HoldenDirector of Care ManagementIndependent Care Health Plan (iCare)

Ed Ortiz

Director of Provider Network Development & Services

Health Plan of San Mateo

Chris Esguerra, MD

Deputy Chief Medical Officer

Health Plan of San Mateo

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Amanda Harcus, iCareJuly 2015

Center for Health Care Strategies

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Why Predictive Analytics?

• Focus on areas of greatest opportunity to make a difference

• Actionable information for care coordinators and aligned providers

• Member level stratification for more effective/efficient care coordination

• Strengthened ability to manage costs and quality

Why Milliman PRM Analytics?

Concerns Off-sets

• Newer (but Milliman endorsed) tool • Current machine-learning algorithms

• Narrowed information & reports • Focused and formatted information

• Middle-cost solution • Speed to deployment (90 days)

• Uncertain ROI value • Proposed 3% MLR savings estimate

• Comprehensiveness • Staff buy-in

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Evaluation

IT Perspective CM Perspectives

• Data • Data

• Standard Format • Good In = Good Out

• Automated File Production • User Interface

• Drag & Drop to File Transfer Protocol • Easy to Navigate & Filter

• User Interface • Easy to Interpret

• Straightforward • Exports to Excel (3000 lines)

• Easy to Navigate and Filter • Each User is Licensed

Requested Changes

• Make “county” a filter option

• Acquire a backend copy of the database details/results

• Incorporate the PRM information into our care management system

• Add additional chronic conditions to filtering options – current limit is 7

• Add company logo to exported reports

• Add user-defined chronic condition groupings

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aharcus@icare-wi.org

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Lisa Holden, iCareJuly 2015

Center for Health Care Strategies

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Plan Predictive Analytics

Description The Milliman PRM tool is predictive in determining members who would benefit from intensive care coordination

Observation PRM could be used to identify members with potentially avoidable costs compared to those members with unavoidable high costs

Goals Transfer these identified members into the iCare Specialty Services (High Risk) Team intensive pre-crisis intervention

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Profile #1

Member Female, 48, Co-Hab, DIA, CKD, Smoker

PRM Avoidable Costs $10,300 next 6 months

Prior Risk Rating Low

PRM Profile History

Findings No glucometer, no dialysis

Acton Engage in special team care

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Profile #2

Member Male, 71, Old ER Data, DIA, CHF

PRM Avoidable Costs $11,900next 6 months

Prior Risk Rating Low

PRM Profile History

Findings Member highly self-activated

Action Disengage, refer to LVAD care

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Profile #3

Member Female, 63, DIA, BH Issues

PRM Avoidable Costs $79,300next 6 months

Prior Risk Rating High

PRM Profile History

Findings Irregular dialysis, high inpatient use

Action Provider/plan surround, education

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Reasons Discussion

24-Month look-back is moving

The Milliman algorithm relies on a look-back of the most recent 24 months of claims data, updated each month

Plan interventions make a difference

Effective interventions will reduce the most recent months of costs causing a reduction in risk

Machine learning is continuous in testingpredicted results

The algorithm components are being adjusted/re-weighted for accuracy as predicted results are changed to actual

Member conditionschange

Member data available via inpatient rosters, encounters, and emergency department reports change even outside interventions

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Plan Personal Coaching Wellness Clubs Telemetrics

Description Community Health Worker/Health Coach

Community Wellness Program

24/7 monitoring of key health conditions

Observation Members respond to specialists who live in the same community, share ethnicity, a common language, socioeconomic conditions and life experiences

Members benefit, if engaged, fromWellness Programs to increase knowledge, skills and abilities necessary to better self-manage health-related behaviors

Members can adopt self-monitoring behaviors with Wi-Fi enabled assists that improve the response time of professional caregiver support

Goals Train members in how to improve their self-management of conditions and use of healthcare resources

Improve the member’s understanding and ability to self-manage their own conditions

Improve monitoring critical health conditions and accelerate response times

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In-Home Health Coaching

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Activation Signals

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Healthy Living with Diabetes -- Aurora-Sinai Medical Center

What’s in it for Me? People taking this workshop show:

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Concurrent ROI Evaluation

PRM-Related Action PlansCoach Club Tele-Monitor Investment ∑$

1) 1 1 1 $$ ∑(∑$)2) 1 1 0 $$ ∑(∑$)3) 1 0 1 $$ ∑(∑$)4) 1 0 0 $$ ∑(∑$)5) 0 1 1 $$ ∑(∑$)6) 0 1 0 $$ ∑(∑$)7) 0 0 1 $$ ∑(∑$)

8) 0 0 0 $$ ∑(∑$)

a) Total Invested ∑$$b) PRM Projected Savings $$c) Actual Savings $$d) ROI c) ÷ a)

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Continuing Concerns and Ambitions

• Prepare internal protocols for STOP/START of PRM-based interventions

• Establish intervention boundaries defined by “law of diminishing returns”

• Concurrently drop/add/refine ROI-based opportunity initiatives

• End-of-life Care • Pre-diabetic Care • Medication Therapy

• Drive selected PRM filtering by already developed intervention strengths

• Share member-level risk information within the prior authorization process

• Attach non-claims data to the PRM Analytics 2.0 algorithm

• Improve understanding of the PRM Analytics algorithm

• Review false negatives to improve predictive accuracy

• Assess PRM Analytics level through all-in Medicare Medical Loss Ratio trend

• Integratepredictive information with the TruCare electronic care record

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lholden@icare-wi.org

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Questions?

To submit a question, please click the question mark icon located in the toolbar at the top of your screen.

Answers to questions that cannot be addressed due to time constraints will be shared after the webinar.

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Effective Targeting of Services and Supports

HPSM Community Care Settings Pilot

PRIDE Webinar

July 21, 2015

Overview

• What is the Pilot?

• Pilot Structure

• Pilot Participant Process

• Targeting Participants

• Participant Engagement

• Spotlight: Housing Strategy

• Member Impact Stories

• Appendix A: Case-Mix Indexing Tool

• Appendix B: Participant Dashboard

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What is the Pilot?

• The Community Care Settings Pilot (CCSP) is our

highest intensity care management program

– Focused on deinstitutionalization and promoting community

living for vulnerable members

– Test-bed for incremental services and tools

– Concept developed Jan/2013, Launched Aug/2014

• Unique features for members include:

– 1:20 case management (MSW/LCSW)

• Significant face-to-face contact

– Housing services & retention

– Multi-disciplinary core group care planning & oversight

• 25+ participants include county government agencies

For appropriate members, CCSP will deploy whatever services are

necessary to migrate out of or avoid LTC residency 43

Pilot Structure

• Operated in partnership with two community-based

organizations selected through an RFP:

– Institute on Aging (IOA): case management and oversight

– Brilliant Corners: housing services and retention

Medical Services & Providers

Community & County-Based

Resources

Intensive Transitional Case Mgmt.

(IOA)

Housing Services (Brilliant Corners)

HPSM

CCSP leverages a number of

resources to support

operations:

• State 1115 waiver programs

(ALW, CCT, IHO)

• County programs (IHSS,

CBAS, MSSP)

• Health benefits and Care Plan

Optional (CPO) services

• Local funding44

Pilot Participant Process

• Phases in the

participant cycle are

designed to ensure:

– Effective use of limited

resources

– Appropriateness of

services

– Safe and successful

discharges

– Longevity in the

community

Population Segmenting

Participant Identification

Engagement & Planning

Migration & Stabilization

Recalibration & Transition

Pilot as a test-bed: lessons learned from deploying this process

have already driven change across the larger HPSM program 45

• Population segmenting: member groupings best fit

to pilot goals & services

• Participant identification: sources of individual

members appropriate for the program

Targeting Participants

LTC Residents

Needs Assessment

• ~10-30% of LTC residents able to migrate to lower level of care

SNF Diversions

LTC Avoidance

• Acute health incidents prompting change in health or functional status

Community Diversions

Extending Independence

• Individuals struggling in the community, at-risk of acute incident or LTC admission

SNF StaffHPSM Case

Managers

Hospital Discharge

Planners

High Utilizer

Reports

County Agency

Case Managers

Supportive Housing

Managers

Social Service

ProgramsPCPs

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Participant Engagement

• Once participants are identified, prep work begins:

• Stepped case management phases:

– Once service is connected, participants receive intensive CCSP

case management for 9-12 months:

• Members are transitioned to a different CM tier

– Brilliant Corners housing retention services continue

Implementation Phase

• Successful discharge

• Frequent home visits

• PCP engagement

• Home setup

Stabilization Phase

• Problem solving

• Regular contact

• Skills development

• Crisis intervention

Transition Phase

• Resolve unmet goals

• Promote independence

• Ensure safety

• Transfer of case

Intake Form

Completed

Scored by

Case-Mix

Indexing

Tool

Assessed

Face-to-

Face by CM

Presented

to Core

Group

Care Plan

Created

Service

Connected

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Spotlight: Housing Strategy

• Housing services are one of the unique elements of

CCSP, delivering a range of supports for project

participants:

• Targeted residential settings:

Person-centered

planning

Housing portfolio

management

Affordable housing

waitlist

management

On-call/ 24-hour

response

Owner-resident

liaison

Rental subsidy

administration

Unit repairs and

modifications

Unit Habitability

and wellness

checks

Existing Home

Affordable

Supportive

Housing

Scattered-Site

Housing

RCFE/ ARF

Assisted Living

Housing has been the main barrier to LTC discharge for many

members, our goal is to remove that barrier 48

Member Impacts

• Intensity of assessment and case management has

identified and resolved many immediate member issues

prior to transition

– Medications, provider engagement, DME needs, IHSS hours

• Examples of key impacts for transitioned members:

Situation Upon Enrollment Post-Transition Impacts

Stroke LTC SNF (1 year)

• Pending eviction from long-time home (affordable

senior apartment)

Returned home (eviction prevented by case manager)

• Connected to CBAS (5x per week) and 4 other

supportive services

• Engaged socially in the community

Shoulder replacement & rehab LTC SNF (1 year)

• Lost Section 8 apartment while in LTC

Section 8 Apartment (voucher extended by case manager

& landlord convinced to accept it)

• Overjoyed to have a home again

Complications from hysterectomy LTC SNF (1 year)

• Depression, substance use

• Previously lived in car, MHRC, Section 8 apt.

Placed in stable apartment

• Regularly visiting community behavioral health provider

and PCP

Stroke, diabetes with vision loss LTC SNF (2 years)

• Previously experienced homelessness

Transitioned to community RCFE

• Bonded with ‘house’ dog at RCFE

• Volunteering with the SPCA

• Self-managing diabetes for the first time

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Appendix A: Case-Mix Indexing Tool

Line of Business

Target Population

Prioritization Factors Cal MediConnect +3

Primary barrier to discharge is housing +1

or Care Advantage

Expressed preference and motivation to return to community +1

SNF Resident +3

Behaviors unlikely to jeopardize potential placement +1

Client income source expected to support community living +1

Medi-Cal only +1

Formal or informal supports motivated to assist client +1

Current placement >90 days +1

Line of Business

Target Population

Prioritization Factors Cal MediConnect +3

Primary barrier to discharge is housing +1

or Care Advantage

Expressed preference and motivation to return to community +1

SNF Diversion +2

Behaviors unlikely to jeopardize potential placement +1

Client income source expected to support community living +1

Medi-Cal only +1

Formal or informal supports motivated to assist client +1

DxCG score > 75th percentile of HPSM members +1

Line of Business

Target Population

Prioritization Factors Cal MediConnect +3

Current housing at risk and/or accessibility issues identified +1

or Care Advantage

Recent history of missing multiple primary or specialty care appts +1

Community Diversion +1

Recent history of lack of engagement with service providers +1

Case management needs exceed those available in community +1

Medi-Cal only +1

Formal or informal supports in need of support to assist client +1

DxCG score > 75th percentile of HPSM members +1

Cal MediConnect

or Care Advantage

12 pts

Medi-Cal only

10 pts

Cal MediConnect

or Care Advantage

11 pts

Medi-Cal only

9 pts

Best Case Scenario 10-12 points

Alternative Case Scenario 8 points

SNF Resident

SNF Diversion

Cal MediConnect

or Care Advantage

10 pts

Medi-Cal only

8 pts

Medi-Cal only

9 pts

Community

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Appendix B: Participant Dashboard

Prospects WaitlistedEnrolled: Pre-

transition

Enrolled:

Transitioned

Closed:

TransitionedClosed Deferred

Totals 11 44 41 34 6 11 41

Target Population # % # % # % # % # % # % # %

LTC Resident 10 91% 16 36% 37 90% 15 44% 1 17% 5 45% 21 51%

SNF Diversion 0 0% 6 14% 2 5% 9 26% 1 17% 3 27% 2 5%

Community Diversion 1 9% 22 50% 2 5% 10 29% 4 67% 3 27% 18 44%

100%

100

% 100% 100% 100% ### 100%

HPSM Line of Business # % # % # % # % # % # % # %

Care Advantage/CMC 8 73% 18 41% 16 39% 23 68% 5 83% 6 55% 18 44%

Medi-Cal Only (No

Medicare) 3 27% 13 30% 12 29% 4 12% 1 17% 4 36% 10 24%

Medi-Cal Only (Medicare

opt out) 0 0% 13 30% 13 32% 7 21% 0 0% 1 9% 13 32%

100%

100

% 100% 100% 100% ### 100%

Referral Source # % # % # % # % # % # % # %

SNF 0 0% 20 45% 36 88% 20 59% 1 17% 5 45% 12 29%

Community 0 0% 23 52% 2 5% 10 29% 4 67% 2 18% 17 41%

HPSM 11 100% 1 2% 3 7% 4 12% 1 17% 4 36% 12 29%

100%

100

% 100% 100% 100% ### 100%

Anticipated Housing Need # % # % # % # % # % # % # %

Scattered Site 9 20% 12 29% 5 15% 0 0% 3 27% 11 27%

RCFE N/A 21 48% 19 46% 16 47% 1 17% 5 45% 20 49%

Other 8 18% 6 15% 3 9% 0 0% 2 18% 1 2%

None 6 14% 4 10% 10 29% 5 83% 1 9% 9 22%

100

% 100% 100% 100% ### 100%

Reasons for

Deferral/Closure # % # % # % # % # % # % # %

Member declined services 0 0% 5 45% 13 32%

Death/hospice 2 33% 1 9% 8 20%

Needs met by other CM

provider N/A N/A N/A N/A 0 0% 0 0% 3 7%

No longer needs services 4 67% 3 27% 7 17%

Not appropriate for

program 0 0% 2 18% 10 24%

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Questions?

To submit a question, please click the question mark icon located in the toolbar at the top of your screen.

Answers to questions that cannot be addressed due to time constraints will be shared after the webinar.

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Contact Information

• Brianna Ensslin bensslin@chcs.org

• Amanda Harcus aharcus@icare-wi.org

• Lisa Holden lholden@icare-wi.org

• Ed Ortiz edward.ortiz@hpsm.org

• Chris Esguerra chris.esguerra@hpsm.org

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