Working with Managed Care
OACCA Conference
April 28, 2014
Timia DelPrete-Brown, Ph.D, LPCC-S
Director, High Risk Care Management
and
Jonas Thom, MA,PCC-S
VP of Behavioral Health
OACCA Conference
Agenda
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What is Managed Care?
Who is CareSource
CareSource Clinical Programs
High Risk Case Management
BH Programs and Covered Services
Opportunities for Collaboration
Q&A
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Mission:
The CareSource Heartbeat
Making a difference in the lives of
underserved people by improving
their health care
Vision
CareSource Management Group will be
an innovative leader in the management
of quality public sector health care
programs
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What is Managed Care?
• Ohio Department of Medicaid (ODM)
‒ A health plan that attempts to control the costs
and quality of care
‒ Operates throughout the state of Ohio
• “Hands-on health insurance"
‒ Combines the responsibility for paying for a
defined set of health services with an active
program to control the costs associated while at
the same time attempting to control the quality
of and access to those services.
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What is Managed Care?
• CareSource
‒ Founded on quality and
service
‒ Delivered with
compassion
‒ Understands Medicaid,
Medicare, and the
associated regulatory
environments
‒ Process efficiencies and
value-added benefits
‒ HEDIS initiatives
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What is Managed Care?
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What is Managed Care?
BH Services
• Ohio Medicaid BH Services
• OMHAS Services
• FFS/Managed Care Services
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Who is CareSource?
• The largest non-profit Medicaid
managed health care plan in Ohio
• 2nd largest Medicaid managed health
care plan in the country
• Established in 1989
– Then known as Dayton Area Health Plan,
CareSource pioneered the state's first
mandatory Medicaid managed care
program in the Dayton area.
• URAC & NCQA accredited
• Headquarters Based in Dayton, Ohio
with offices in Cleveland, Columbus,
and Kentucky
• Recent partnership/alliance with
Humana
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Who is CareSource?
• CareSource serves
950,000+ Ohio citizens
• CareSource contracts with
24,000+ Ohio providers
• CareSource employs
1,500+ individuals
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Care Source
Health Services Division
Quality Improvement
Care Management
Pharmacy
• CareSource 24
• Disease Management
• Care Transitions/Bridge to
Home
• High Risk Case Management
Health and
Wellness
Behavioral
Health
Medical
Management
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CareSource Programs
Quality programs
• HEDIS
• Support quality care
• Medical Management
• Identify services/resources
• Prior authorization management
• Quality Improvement
• Entry point for member voice and
continuous quality improvement
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CareSource Programs
• Disease Management
‒ Self Management
‒High risk Asthma
‒Diabetes
‒ Different levels of DM
‒ Proactive calls
‒ Minimum contacts
‒ Smoking Cessation
‒Informal connection
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CareSource Programs
Triage/CareSource24
• Assess the severity of the member's
symptoms and guide the caller to the
appropriate level of care
• Assists members in navigating the
healthcare system while educating and
empowering the member.
• 24 hours a day, 7 days a week
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The Care Transitions
Program
• Bridge To Home:
• Contact each member having a hospital or skilled
nursing facility confinement within 14 days of
discharge
– Adherence to scheduled primary/specialty care follow up care
– Medication reconciliation and education
– Identification of potential member gaps in understanding discharge
instructions or changes in the member’s medication regime post
discharge
– Assessment and identification of member educational needs with a
focus on member self-management and knowledge of the
member’s individual triggers and individualized
care treatment plan
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CareSource Programs
• Population Specific
‒ Coordinated Services/Care4U
‒ Opiate RX abuse
‒ 12+ active RX, 4 docs/pharmacies
‒ Care management and coordination
‒ Prenatal/NICU
‒ Manage high risk pregnancies
‒ Child is in the NICU
‒ ABD Children
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Who are the ABD Children?
• There are approximately 37,000 Ohio
children who are eligible for Medicaid due to
a disability
• On July 1, 2013, ABD children were enrolled
in a one of Ohio’s Medicaid Managed Care
Plans
• Exclusions included those eligible for
Medicaid on waivers, children who reside in
institutional settings, or children who received
both Medicare and Medicaid benefits
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Top Complex Medical
Conditions for Children:
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Developmental disorder
Epilepsy
PDD & Mood Disorders
Bipolar disorder
Deaf
Anoxic Brain Damage
Cardiac Septal Defects
Traumatic brain injury
Spina Bifida
Substance Dependence
Psychotic disorders
Sickle Cell
Blind
Transplant Status
Quadriplegia and paraplegia
Cancer diagnosis
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ABD Children's Advisory
Council
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Developed in March 2012
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Charged with providing CareSource staff and stakeholders with key
recommendations for ensuring children with special health care needs are
successfully transitioned to the health plan
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Recommendations led in developing strategies for attaining the best
possible health outcomes for these newly eligible children
 Family Voices
 Parent Advocate
 Ohio Council of Behavioral Health &
 Nationwide Children's
Family Services Providers
 Easter Seals
 Children’s Defense Fund
 BCMH
 Voices for Ohio’s Children
 Ohio Association of
 University Centers for Excellence in
Children Services
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 Ability Center of Greater
 Dayton Children’s Hospital
Toledo
 Respite Coalition
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ABD Children's Top Chronic
Conditions
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Who Are High Risk
Members?
• ODM compiled utilization data regionally and
nationally (“Hot Spotters” article published in New
Yorker magazine)
• ODM determined that a very small percentage of
members are driving Medicaid (ABD & CFC) costs.
Those individuals are known as “hot spotters”
• ODM mandated that all managed care companies
operating in the State of Ohio revise their case
management model to focus on the top 1% of “hot
spotters”
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What Are the Program’s
Requirements?
• ODM’s Requirements:
• Need-based guidelines
• High Risk, top 1%
• Mobile and community
based workers
• Face-to-face & telephonic
interactions with
members
• 1:25 staff/member ratio
• Reimbursed for improved
health outcomes (HEDIS)
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High Risk Care Management:
Community Based Model
Multidisciplinary
team approach
• Members/Caregivers
• Case Managers
• LPN’s
• Social Workers
• Patient Navigators
• Care Management
Support Specialists
• PCPs and Specialists
• Community Partners
Integrates
professional
Standards of
Practice
Coordination
of member’s
health care
needs across
care
continuum
Focus on
quality
outcomes,
regulatory and
accreditation
requirements
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What is CareSource’s High Risk
Case Management Model?
• Incorporates the Case Management
Society of America and the American
Association of Managed Care
Nursing Standards of Practice
– Commitment to the CM Process:
identification, assessment, planning,
facilitation, monitoring, evaluation, &
advocacy
• Integrates the Harold P. Freeman
Patient Navigation model
• Integrates behavioral and physical
health intervention strategies
• Utilizes a multidisciplinary team
approach
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High Risk
Case Management
Components
Identification
• Predictive modeling
• Health risk
assessments
• Provider and
community referrals
Engagement
• Face-to-face
meetings at least
quarterly with
ongoing regular
telephonic contact
• Assessment of
member’s needs
• Planning,
facilitation,
intervention, and
advocacy to meet
identified needs
• Ongoing monitoring
and evaluation of the
case management
plan
Outcomes
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Clinical
Financial
Satisfaction
Quality of Life
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Who Are High Risk
Members?
•Identification Mechanisms:
1. Referrals from CareSource’s Medical
Management Department
2. Referrals from CareSource’s data
department based on electronic
Predictive Risk Modeling – John
Hopkins University ACG software
combines medical, behavioral health,
and pharmacy claims, creating clinically
relevant categories as well as risk
scores for our members
3. Referrals from provider & community
partners who work with members in
crisis on a daily basis, in real-time
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High Risk Care Management
Demographic
Cost
Predictive
Modeling
Utilization
Diagnosis
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High Risk Criteria
Greater than four chronic co-morbidities
(such as: DM, CAD, HTN, CKD, COPD, Asthma, SCD, HIV)
Behavioral health diagnosis including Schizophrenia, Major
Depression, Bipolar Disorder
A sudden disability (e.g., stroke, head injury, spinal cord
injury, paraplegia)
Hospital re-admit within 90 days
Multiple avoidable ER visits in the past 6 months
Greater than 12 prescriptions or high cost drugs
High Risk pregnancy
Unable to access PCP/unable to keep or get to preventive
visits
Limited or no caregiver resource
NICU admission > 7 days
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Focus of High Risk Case
Management
Member-driven case management process
Help members regain optimum health and
function
Promote adherence with prescribed treatment
plan
Self-management education, preventive care
support
Improving health outcomes and health care costs
Partnership with providers to maximizes benefits
of primary care and medical home
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What Services Does
CareSource’s High Risk
Case Management Program
Provide?
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Care Coordination
Health Promotion
Advocacy & Access
Outreach
Linkage for Basic
Needs
• Collaboration
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Care Coordination
The Primary Service of High
Risk Case Management.
Facilitate care across health,
social and enabling services
through:
• Comprehensive health assessments:
bio, psycho, social, spiritual
• Individualized care plans based on
Member’s strength, needs, and
preferences
• Identification and inclusion of all
providers
• Provision of clinical and service
summaries, such as the Provider
Portal
• Proactive communication with all
providers, members and families
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Health Promotion
Skill & asset building to help
members mange their illness
and maximize wellness through:
• Developing understanding about
their conditions and importance
of treatment/medication
adherence
• Utilizing available treatments
and pathways to health
• Building skills and resources for
self-management and wellness
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Advocacy and Access
Ensuring members have
the services and
resources they need
across:
• Healthcare providers
• Social service systems
• Enabling services, such as
transportation and peer
support
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Outreach
Community based work,
to engage members in
healthcare, including:
• Serving members “where
they are,” based on their
preferences
• Assertive engagement,
including home and
provider visits
• Identifying health and
support resources
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Linkage for Basic Needs
Linking members and
families to resources
that are prerequisites
to healthcare:
• Food
• Clothing
• Shelter
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Collaboration
CareSource Members + Family
CareSource
RN Case Manager, Social Worker, Behavior Health,
Patient Navigator, Disease Management,
Pharmacy, Care Transitions
Primary Care Physician
Community Services
Community Behavior Health
YMCA
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Collaboration (cont.)
CareSource’s Provider Portal:
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Confirm member’s eligibility
Review coordination of benefit information
Submit prior authorizations
Review care plans
Make referrals for care or disease
management
• Review individual member or practice HEDIS
measures
• Review the Clinical Practice Registry
• Review the Member Profile
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HRCM Program Evaluation
• Quality
• HEDIS
• Condition Specific
• Satisfaction
• Survey
• Grievances
• Cost
• Overall Medicaid
costs
• ED utilization rates
• Inpatient rate
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BH Strategy: Enhance our
clinical programs
• Embed BH Specialist into all CM teams
• BH Coordinator role for BH Specialist staff
• Ongoing training and learning for all clinical
staff
• Deploy “BH Pathways” for all member
facing staff
• Ensure CM, MM, & Care Transitions
collaboration
• Provide member self-management tools
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BH Strategy: Web Based
Tools
• Provider Portal
• Health Home Portal
• Snapshots
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BH Strategy: Improve
provider services
Access
• Availability of BH in primary care
• Telehealth
• Fill gaps in CMHC care
Care Coordination Resources for BH Providers
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Integrate staff
BH Provider data sharing solutions
Medication interventions
Provider and stakeholder education
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BH Strategy: Advocacy
Lead local, state and federal advocacy
• Initiatives
• Regulatory alignment
• Plan Alignment
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We want to collaborate
with you!
• CareSource Programs
• Tools and Resources
• Specific Partnerships
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We want to collaborate
with you!
CareSource Programs
• Participate with our shared
members in our programs
• Work with our community based
care management!
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Collaborations
Tools and Resources
• Member Profile
• Clinical Practice Registry
• Care coordination
• Inpatient notification system for BH
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Collaboration
CareSource Provider
Portal
(right) Clinical Practice
Registry
(below) Case Management
Referral
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We want to collaborate
with you!
Specific Partnerships
We want to work with you to help members…
Do you …
• Know your Member’s payers?
• Understand OH Medicaid programs’
coverage?
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Summary
• CareSource thrives on partnerships
‒ Open to creating new ways to partner
• More Behavioral Health services not less
‒ BH is essential to overall health wellness
and community tenure
• Contact
Jonas Thom, M.A., PCC-S
Vice President of Community Programs
‒ jonas.thom@caresource.com
‒ 937-531-2137
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Questions?
Contact Information:
Timia DelPrete-Brown
Timia.DelPrete-Brown@caresource.com
(216) 896-8205
Jonas Thom
Jonas.Thom@caresource.com
(937) 531-2137
Terry Jones, Director of Behavioral Health
Terry.Jones@caresource.com
(937) 531-2401
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Mission:
The CareSource Heartbeat
Making a difference in the lives of
underserved people by improving their
health care
Vision
CareSource Management Group will be an
innovative leader in the management of
quality public sector health care programs
49