Care Coordination for the
Chronically Ill:
Minnesota Senior Health Options
Alliance for Health Reform Briefing
August 11, 2011
Pamela Parker
Special Needs Purchasing
Minnesota Department of Human
Services
pam.parker@state.mn.us
Medicaid Managed Care For
Chronically Ill in Minnesota



Minnesota SeniorCare Plus (MSC+): Mandatory enrollment for 65+
including dual eligibles statewide in all settings and levels of care.
Began in 1983. Includes Medicaid primary, acute and long term
care services, contracts with 8 Medicaid plans. Medicare is fee for
service. 11,500 enrollees.
Minnesota Senior Health Options (MSHO): Fully integrated
Medicare/Medicaid program, voluntary enrollment as alternative to
MSC+ for dual eligibles 65+, statewide in all settings and levels of
care. Highly integrated primary, acute and long term care services,
contracts with Medicare Advantage Dual Eligible Special Needs
Plans (SNPs) sponsored by the 8 MSC+ plans. 37,000 enrollees
Special Needs BasicCare (SNBC): Voluntary enrollment for people
with disabilities 18-64, includes Medicare and Medicaid primary,
acute and behavioral health services including all mental health
case management, most long term care is carved out, delivered
through 4 SNPs and 1 Medicaid only plan, 6,000 enrollees, now
expanding statewide under new legislation
Minnesota Senior Health Options




MSHO enrolls 70% of Minnesota’s Medicaid seniors and attracts
the largest proportion of seniors with long term care needs
MSHO primarily enrolls dually eligible seniors who already have
high chronic disease rates and multiple chronic conditions
Average age of members is about 81
72% of MSHO members require long term care services






30% reside in nursing homes (most are residents prior to Medicaid eligibility)
42% receive home and community based services
28% are community non-frail
Dementia rates are more than 3 times greater for nursing home
residents than for those served in community settings
Aligned integrated full risk financing from both Medicaid and
Medicare under MSHO provides incentives for managed care
organizations to improve care coordination strategies across all
services and care settings
Addition of Medicare through SNP contracts enables more
intensive models of care coordination compared to nonintegrated programs (MSC+)
MSHO Care Coordinator Functions






All members are assigned an individual care coordinator
(Nurse Practitioners (NPs) RNs, Social Worker (SW) )
Care Coordination models blend social and chronic care
management approaches across all services
Care Coordinators conduct risk assessments, monitor
chronic conditions and transitions, facilitate annual primary
care visits, communication with physicians and preventive
care, and authorize home and community based services
Care Coordinators provide referral and coordination with
disease and medication management programs
Care Coordinators also implement system wide quality
improvement programs/interventions
SNPs provide data to care coordinators to follow up on
specific member chronic care needs (eg diabetes or CHF
care)
Many Flowers Bloom:
Multiple Care Models





Clinic Care Systems: (may also be Health Care Homes)
capitated or virtual caps with gain/risk sharing, includes MD
teamed with NP and SW
SNP Care Coordination: SNP based care coordinators
assigned to work with a clinic or group of clinics in their
network
Care Management Organizations: SNP contracts with
community or provider organizations serving specialized
populations (behavioral health, people with disabilities, or
immigrant groups)
SNP Contracts with County Social Services: especially used
in rural areas
Health Care Homes: SNPs required to cover payment as a
Medicaid service, MN is an all payer HCH state
Reality Check






Goal is to provide increased incentives for Total Cost of
Care/HCH models to reform provider service delivery
But Total Cost of Care and NP models are difficult to
implement statewide due to lack of provider capacity or
interest
SNPs must also rely on existing resources (county social
services, community organizations, clinics, behavioral
health) to meet total medical/social needs
SNPs have built increased chronic care management into
county social service care coordination contracts
Goal is to build more formal communications linkages
between HCH and community social services care
coordination functions
As more HCH are certified, SNPs may facilitate blending of
county social service models with HCH
MSHO Results







MSHO satisfaction highest of all state managed care
programs, dis-enrollment is very low
MSHO has increased access to community services,
shows reductions in expected use of nursing homes, and
community services PMPM costs are less than forecasted
98% of MSHO seniors have annual primary care visits.
MSHO shows reduced hospitalization rates for Ambulatory
Care Sensitive Conditions (ACSC) for asthma, bacterial
pneumonia, congestive heart failure, dehydration and
diabetic complications between 2006-2009 (most recent
data available).
Numerous performance improvements for seniors have
been implemented system wide
All MN SNPs scored 100% on CMS Structure and Process
measure related to integration for 2010.
7 of 8 MN SNPs scored 4 or above on the CMS MA Star
Ratings
Where We Need to Go





New ACA pathways for aligned financing for dual eligibles
provide exciting opportunities for building platforms that improve
chronic care coordination!
Medicare, rather than Medicaid, should cover HCH payments for
dual eligibles since Medicare is primary for physician services.
Medicare risk adjustment appears problematic for Dual SNPs
designed for people <65 with disabilities. Several MN Medicaid
plans had to drop their Medicare SNPs for that group when the
Medicare bid process resulted in premiums that dual eligibles
cannot pay. Medicare risk adjustment needs to better capture
costs for SNPs specializing in serving people with disabilities
and the bid process needs revamping for Dual SNPs.
The ACA provision for frailty adjustor for FIDES SNPs also needs
revision. MN SNPs don’t qualify because the State requires them
to enroll community non-frail members.
Need flexibility for States to de-link service and eligibility tiers
between institutional and community based care to improve
targeting of care and services.
CASE STUDIES
(A Few Examples of Many Care Coordination
Strategies Being Used by MN D-SNPs)
Use of Aligned Financing








MSHO SNP authorizes additional Intensive Service Day payment to
nursing home for 70 year old resident who needs highly intensive
rehabilitative care, wheel chair bound, ventilator dependent, and
post polio with tracheotomy and wound care. This reduces need
for additional hospitalizations.
SNP provides regular check in by Care Coordinator with nursing
facility to monitor care.
At first resident is expected to remain in nursing home long term
because of dependence on vent so after 100 day Medicare stay is
over, SNP pays for nursing home care under Medicaid managed
care custodial care benefit.
Resident becomes more motivated to wean from vent and return
home.
Additional respiratory therapy provided reduces need for
ventilator.
Care Coordinator develops Community Support Plan for return
home.
Community based services are arranged (ramp, home health aide
and RN visits, Lifeline).
About six months after entering nursing home, resident returns
home with more control over managing health and independence.
This case study is courtesy of Blue Plus
Other health plans also have similar case studies
Medication Therapy Mgmt
(MTM) Project



Sponsored by Medica with QIO Stratis Health,
expanded to include other MN Dual-SNPs
Goal: Reduce potentially inappropriate medication
(PIM rates and Drug-Drug Interaction (DDI) rates for
MSHO members.
Interventions:






Pharmacist medication review and member education
Pharmacist to provider- recommend changes
Care coordinator training and education on MTM with care
coordinator referral to an MTM pharmacist
Care Coordinator training and education on drug safety (list
of common PIMs and DDIs)
Medical Director Support
Results: on track to exceed goal of 3% reduction