Moving Forward: The Changing Landscape of Case Management

Meghan Shineman

NYC Department for the Aging (DFTA)

Aging Concerns Unite Us (ACUU) 2019 Conference: Workshop E3 -- Moving Forward: The Changing Landscape of Case Management

About DFTA

New York City Department for the Aging (DFTA):

DFTA is one AAA that serves the five counties of NYC

Approximately 1.5 million people 60+ years old live in NYC

DFTA reaches about 230,000 seniors, caregivers, and others through its programs

DFTA contracts with a network of over 400 contracted CBOs

DFTA Programs with Case Management/Assistance

Case Management Agencies (CMA) o 21 geographically-based CMAs serve about

22,000 seniors annually

o CMAs assess eligibility and turn on Home Care and Home Delivered Meals (HDM). 3,000 seniors receive home care from 5

providers

18,000 seniors receive HDM from 23 providers

Caregiver Programs 7 geographic and 3 special population programs serve

about 11,000 caregivers

Senior Centers 249 centers attract 28,000 people/day

NORCs 28 NORCs serve about 11,000 clients

Elder Abuse Prevention and Intervention One office in each of the 5 boroughs; DFTA houses a

resource center

Additional DFTA Services

Health Insurance Information, Counseling and Assistance Program (HIICAP)

Thrive NYC o Friendly Visiting Program

oGeriatric Mental Health Initiative

Grandparent Resource Center/ Foster Grandparent Program

Senior Employment

Bill Payer Program

Assigned Counsel Project

Safety Monitoring Resources

Transportation

Social Adult Day Care

NY Connects One office in each of the 5 boroughs

Other DFTA Initiatives

Care Transitions through DSRIP – more formal relationship with NYC’s public hospital system (H+H)

CommunityCare Link (CCL) oNetwork model offering back-office

admin services to help bridge the aging & health sectors in NYC

DFTA Case Management

Assessments are conducted to identify strengths and needs of older adults, and arrange/coordinate services such as:

Assessment & referrals to community resources

Financial screening for benefits & entitlements

Gatekeeper to DFTA-funded services (HDMs, home care, elder abuse, friendly-visiting, bill payer, and mental health)

Assistance & counseling on non-DFTA services (i.e. long-term care, respite, and housing options)

COMPASS Assessment

Health-specific elements

Other elements

• Health status: insurance, provider info

• Medical history • Recent healthcare

events • Use of assistive

devices • Screens for

depression, alcohol, and nutrition

• Psycho-social status • Medications • ADL/IADL needs

• Client demographic & contact Info

• Housing status & home safety checklist

• Service & benefit eligibility and receipt

• Informal support status

• Monthly income • Legal info/advance

care planning (optional)

DFTA COMPASS Supplemental

Supplemental screens for:

1) Physical health issues (i.e. falls, oral health)

2) Cognitive/Mental health issues

3) Family/Informal caregiver support

4) Housing issues

5) Elder abuse/neglect issues

6) Eligibility for home-delivered meals

Future Focus of DFTA Case Management

DFTA has been enriching case management, including screening and connections to:

• Oral care

• Mental health

• Vision & hearing

• Falls prevention

Home Meds pilot = expanded in 2019

Health Benefits of Case Management

Impact on client’s health & wellbeing:

Assist clients in accessing appropriate services, benefits, and entitlements needed to age safely at home and maintain their quality of life

Coordination to social services (social determinants of health)

Reduces social isolation among largely homebound clients

Eases caregiver burden

How can integration with health care benefit CMAs?

Better coordination of care across all programs makes for a better client/patient experience

Access to RHIOs/SHIN-NY can provide more timely health information about clients, including hospitalizations

Paid relationships offer more sustainability and capacity to decrease wait lists

Lessons Learned from Health Partnerships

Different organizations cultures and requirements (e.g. onboarding personnel procedures, compliance rules)

Different patient tracking IT systems = duplication of effort & inconsistent information

Value proposition or Proof of concept

True integration with healthcare will yield more appropriate and sufficient number of referrals as well as more targeted and effective interventions

What Does the Future Hold?

Value-based Payment resulting from DSRIP (for Medicaid/MLTC health plans)

Chronic Care Act / Medicare Advantage Supplemental Benefits

Increased presence of SDH screenings and electronic (closed-loop) referral systems

Improving Health Outcomes by Addressing the Social Determinants of Health

June 12, 2019

2019 Aging Concerns Unite Us

Denard Cummings, Director

Bureau of Social Determinants of Health

June 2018

Bureau of Social Determinants of Health

June 2018

Bureau of Social Determinants of Health

History

BSDH established in January 2018 (formerly

BSH) to implement the VBP Roadmap

requirement regarding Social Determinants

of Health and Community Based

Organizations

Purpose

Transform the New York State Healthcare

delivery system by integrating health and

human services. Addressing the Social

Determinants of Health to improve the

quality of care and health outcomes for NYS

most vulnerable populations.

Health Systems

Data

Medicaid Reform

Health Outcomes

Community Based

Organizations

BSD

H

June 2018

What are Social Determinants of Health?

June 2018

Social Determinants of Health

June 2018

The 5 Domains of Social Determinants of Health

June 2018

Factors Correlated with Health Outcomes

Determinants of Health. (n.d.). Retrieved from https://www.goinvo.com/features/determinants-of-health/

June 2018

Healthcare Spending in the US

June 2018

Health Care Spending in US & Other Countries

June 2018

Health Care and Social/SDH Spending

June 2018

Health Care Quality, Health Care Spending, and Social/SDH Spending

June 2018

Changing the Healthcare Delivery Conversation

June 2018

Case Study

Philip’s Story

• Homeless

• Food Insecure

• Crime History

• Chronic Comorbid Conditions

• History of Substance Abuse

• Cognitive Limitations

• No Informal Support System

• 160 Emergency Room Visits one year prior to intervention

June 2018

Case Study – Philip’s Story

• Health Home Enrollment (Coordination of Care)

• Supportive Housing Intervention

• Nutrition Intervention

• Reduction in Law Enforcement Interactions

• Reduction in Emergency Room utilization from 160 visits annually to 20 visits the year following the intervention

June 2018

Housing Security: Outcomes of MRT Supportive Housing

Housing is Healthcare!

Number of high-need Medicaid recipients served to date: 12,000+

June 2018

Food Security: Food is Medicine

• Low-cost/High-impact intervention: Feed someone for half a year by saving one night in a hospital

• Reduce overall healthcare costs by up to 28% (all diagnoses compared to similar patients not on MTM)

• Reduce hospitalizations by up to 50% (all diagnoses compared to similar patients not on MTM)

• Reduce emergency room visits by up to 58% (pre-post MTM intervention)

• Increase the likelihood that patients receiving meals will be discharged to their home, rather than a long term facility (23%) (all diagnoses compared to similar patients not on MTM)

• Increase medication adherence by 50% (pre-post MTM intervention)

God’s Love We Deliver – Medically

Tailored Meals

http://www.glwd.org

June 2018

NYS Value Base Payment Roadmap

June 2018

Value-Base Payment Arrangements

• DOH has approved 74 SDH interventions and CBO contracts

• Approved CBO contracts reflect both direct contracting with MCOs and sub-contracting with VBP providers (i.e. hospital, IPA, ACO)

• CBO contract outlines: • scope of intervention

• success metrics

• date sharing agreement

• reporting requirements

• Most CBO contracts are structured as payment for services rendered

June 2018

Advancing Care with CBO in VBP

Experience addressing social determinants of

health and navigating local community

Follow up with patients

Find and engage disengaged patients

Provide non-medical services that address

barriers to improved patient health outcomes

Overcome cultural competencies, geographical

and language barriers

Report back outcomes and ensure patient

centered care

June 2018

For Additional Information:

https://www.health.ny.gov/mrt/sdh

Contact Us:

Bureau of Social Determinants of Health

SDH@health.ny.gov

Thank you!

Dr. Mary Ann Spanos OFA/AAA Director

Chautauqua County, New York

Growing Aging Population

Traditional Funding (AOA & State) ◦ Stagnant or not stable

◦ Funding not adequate for need

◦ Out of our control

Developing new funding sources ◦ Stable revenue source

◦ More control

◦ Growth depends on you!

2011 2018

Set a price and sell your services to: Private pay Medicaid LTC plans Doctors Hospitals

Services Dietician Services EBI Programs Home Care Home

Repairs/Access Home Delivered

Meals PERS Social Adult Day Transportation

Combine forces with subcontractors

Can grow staff as business increases

Little Risk/Liability ◦ Doing the same work for a new set of payers

New Revenue & Profit ◦ Profit sharing with subcontractors

◦ Reduce wait list for services

◦ Expand services to more seniors

◦ Revenue reinvested to meet rising demand

Contract Development (Legal & Finance team)

Referral Procedures (Fax, e-mail, Peer Place)

HIPAA Compliance Billing

◦ Forms & how to complete ◦ Electronic portal & clearing house

Credentials ◦ NPI (National Provider Identification) Number ◦ W9 Form for the County ◦ County Tax ID number ◦ Insurance/Liability coverage

Miscellaneous (Vendor Data Form) ◦ ADA checklist (any building where services occur) ◦ Policy & Procedures ◦ Proof Program Standards/oversight ◦ Client Bill of Rights ◦ Monitoring

Low Risk ◦ Paid for quantity ◦ Only get paid for what you produce

◦ Volume unknown but usually grows over time

Pricing ◦ Time to evaluate full cost ◦ Ensure OAA not subsidizing ◦ Renegotiate if needed-Build in profit

Process & Procedures ◦ Grow slowly ◦ Develop work flow of referrals ◦ Billing procedures : Paper vs Electronic ◦ Monitor & adjust

Payers & Population Goal based payment

Payers

◦ Medicare/Medicaid

◦ Medicare Advantage

◦ Private Insurance Plans

Population

◦ Everyone in a particular area

◦ All Diabetics (any age)

◦ High utilizers (any age)

Paid for outcomes

◦ 50% of “no shows” to MD

◦ 80% screened for falls risk

◦ Quality vs Quantity

Package of Services based on:

◦ Needs of the payer (HEDIS)

◦ Reducing cost High needs clients

◦ Connecting with non-utilizers Paid for Value/Quality

◦ How you reduce payers costs

◦ Ability to get clients to engaged

◦ Get clients to PCP instead of ER

◦ Avoid Hospitalization

◦ Improve HEDIS measures Payment may involve Risk

◦ Pay for Performance.

◦ Only paid if quality metrics are met. (I.E. Decrease ER usage)

Reduce Costs: Short-term Preventative: Long-term

Connect to regular care

Stop high use of ER

Prevent avoidable admissions

Focused on…

Meeting clients where they live

Patient activation

◦ values & goals

Non-medical barriers

◦ Social/environment

◦ Economic/housing

◦ Transportation

Teach self-management Longer-term education ◦ Evidence based

◦ Older learner-focused

Screen for risk & address Connect to resources Exercise programs ◦ Evidenced-based

OFA Case Management Options Counseling

Differs from Medical CM

Person Centered Assessm.

Community Care Focus

Assess Client’s abilities

Social supports or lack

Deploy network of community care options

Regular follow-up to address emerging needs

Long-term relationship

Assess client’s needs & goals Person-center planning Eval. social supports Connect & deploy resources Provide follow up Coaching in self-management

Current Case Management Future Case Management

Working with 60+

Annual Assessment ◦ 2 Month follow-up

Options counseling ◦ Periodic Follow up

Person Centered Plans

Care Coordination Any Age Care Transitions

Intervention ( CTI) with 30, 60, 90 day follow up

Options counseling with monthly f/u & transport assist

Fall prevention Package screen, in-home assessment & f/u classes.

Medication Compliance (In-

home medication review, Pharmacist review for interactions