First Choice VIP Care PLUS A Healthy Connections Prime Medicare-Medicaid Plan

Model of Care (MOC)

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Model of Care — Why First Choice VIP Care PLUS Was Created

The First Choice VIP Care Plus plan was created to offer Medicare and Healthy Connections Medicaid eligible beneficiaries the opportunity to receive coordinated benefits and efficiently and effectively manage their care.

The goals of creating this plan are to:

• Improve health outcomes.

• Keep beneficiaries in the community.

• Simplify the delivery system and align payments for the provider.

How is this accomplished? Through the Model of Care.

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What Is the Model of Care?

The Model of Care is:

• A high quality, patient centric medical care delivery system for dual eligible Medicare-Medicaid members.

• An approach of bringing multiple disciplines together as a team to provide input and expertise for a member’s individualized care plan.

• Part of a plan designed to maintain the member’s health and encourage members’ involvement in their health care.

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Why the Model of Care is Necessary

• There are approximately 9 million dual

eligibles in the United States.

• They are more sick and frail than the general Medicare population.

• 21% of Medicare population =

31% of Medicare costs

• 15% of Medicaid population =

39% of Medicaid costs Reference: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8353.pdf

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They are:

• Three times more likely to live with a disabling condition.

• More likely to have greater limitations in activities of daily living (ADLs), such as bathing and dressing.

• More likely to suffer from cognitive impairment and mental disorders.

• Indicated to have higher rates of pulmonary disease, diabetes, stroke and Alzheimer’s disease.

• More likely to be in need of in-home care providers, plus a range of doctors and other health and social services, due to these high health needs.

Medicare Payment Advisory Commission (MedPAC). Report to Congress: New Approaches in Medicare, Chapter 3: Dual Eligible Beneficiaries, an Overview, June 2011.

Model of Care - How Medicare-Medicaid (Dual) Eligibles Are Different from the General Medicare Population

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Model of Care — Outlining the High Volume = High-Cost Issue in the Dual-Eligible Population

Issues in the dual-eligible population that increase costs include:

• Frequent emergency room (ER) visits.

• Readmissions to hospital.

• Long-term skilled nursing facility stays.

• Poor medication adherence.

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Model of Care — Why Dual Eligibles Are Special-Needs Members

Note: Mental impairments were defined as Alzheimer’s disease, dementia, depression, bipolar disorder, schizophrenia or mental retardation. Source: Kaiser Family Foundation analysis of the Medicare Current Beneficiary Survey, 2008.

Under age 65 39%

Facility 13%

Mental impairment

49% 0 or 1 Chronic

conditions 25%

Ages 65 – 74 26%

2 Chronic conditions

20%

Ages 75 – 84 21%

Community 87%

No mental impairments

51%

3 Chronic conditions

20%

Ages 85+ 14% 4 or more

chronic conditions

35%

Age Type of Residence Mental Impairments Number ofChronic Conditions

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Building the Model of Care Multidisciplinary Team (MT)

An integral part of the MOC is building a MT. This begins with the development of a First Choice VIP Care Plus Care Team. Both the providers and members have access to this team which helps members modify their behavior and how they access health care.

The First Choice VIP Care Plus Care Team includes:

Personal Care Connectors Community Health

Navigators Care Coordinators

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First Choice VIP Care PLUS Care Team Roles & Responsibilities

Personal Care Connectors I

All Customer Service Functions

Provider Lookup / PCP Assignments

Quoting Benefits Initial Health Screening

Personal Care Connectors II All Customer Service Functions

PLUS Model of Care Elements

General Appointment Assistance Medicaid Re-Certification Triage to Model of Care

Non-Clinical Call Campaigns Gaps in care reminders

Community Health Navigator In-person engagement

Links member to health and social service system

Assists with basic navigation such as shopping and transportation Accompanies member to key

appointments Coaches for behavior change and

condition management

CICO Care Coordinator In-Home Assessments Develops plan of care

Member Care Team Leader Local PCP Outreach

Transition Coordinator

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How the Care Team Help Members

The Care Team understands the most common diagnosis is poverty. • Help address limited resources in all aspects of a member’s life that will impact medical care and costs. • Build trusted relationships. • Monitor changes in condition.

• Advocate for the member.

• Overcome barriers to better adherence to medication and self-care regimes.

The Care Team knows that transitions of care are major events. • The Care Team is involved in assisting the member and the provider with managing the details across settings

to prevent readmissions.

The Care Team knows that caregiver involvement is critical.

• The Care Team helps identify capable resources (such as friends, family and agencies) who can provide members with better care and the Care Team with a more objective perspective.

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Continuing to Build the Model of Care Multidisciplinary Team (MT)

The MT is crafted to serve the individual needs of each member and is completed by including the First Choice VIP Care Plus Care Team along with the following, if applicable:

• The member*

• The primary care provider or medical home.*

• Health plan nurses, medical directors and pharmacists.

• Physical and behavioral health specialists.

• Home health care providers.

• Social workers.

• Community mental health workers.

• Physical, speech and occupational therapy providers.

• Others who play an important role in their care - family members, friends, pastor, etc.

*required

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The primary care provider/medical home is the main provider responsible for overseeing the overall care of the member. The key responsibilities of this role include:

• Helping members determine which services they need.

• Connecting members to the appropriate services.

• Serving as a central communication point for the member’s care.

• Reviewing the plan of care sent by First Choice VIP Care Plus.

• Providing feedback to First Choice VIP Care Plus.

Multidisciplinary Team and the Primary Care Provider/Medical Home’s Roles

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Working Together with the Multidisciplinary Team

Collaboration between the care team care coordinator, the member, and the multidisciplinary team, yields a Member Individual Care Plan and a Health Action Plan that are specifically designed to meet the member’s health and personal needs.

The team will be in charge of coordinating the needed services. For example:

• The care team will make sure the doctors know about all medicines a member takes so they can reduce any side effects.

• The care team will make sure a member’s test results are shared with all of the member’s doctors and other providers.

• Primary Care Physicians will be responsible for directing the member’s care.

• The development and any updates needed to the Individual Care Plan (ICP).

• Manages medical, cognitive and psychosocial needs of member.

• Works together as a “team” to ensure best outcomes for the member.

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The First Choice VIP Care PLUS Member’s Introduction to the MT

Primary Care Physician

Member selects PCP upon joining First Choice VIP Care Plus.

Care Manager/Care Coordinator

Comprehensive and Home Safety assessment is completed with the member.

MT

Comprehensive and Home Safety assessment is shared with the MT.

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The First Choice VIP Care PLUS and the Individualized Care Plan

Multidisciplinary Team

MT develops the Individualized Care Plan (ICP)

Primary Care Physician

PCP accesses and approves the ICP through Provider Portal on NaviNet

Care Manager/Care Coordinator

The Care Manager and Care Coordinator work with the member to achieve the goals of the ICP.

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The First Choice VIP Care PLUS Member’s Updating the ICP

Primary Care Physician

PCP updates the ICP with changes to the members status by logging into NaviNet and submitting information to First Choice VIP Care Plus through the Member Care Plan.

Care Manager/Care Connector

Care manager documents information received from the PCP and makes edits to the ICP.

Multidisciplinary Team

MT reviews the edits and suggestions and approves a revised ICP.

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Ancillary Durable medical equipment (DME)

Mental health Rx

Specialists

Personal Care Connector

Care Coordinator

Member single point of contact

Provider single point of contact

Member/family Coordinated care

VIP Plan Multidisciplinary Team

Primary care The VIP Care Model provides a single point of contact for the member and for the primary care provider.

One contact

LTSS

Multidisciplinary Team: • Member. • Medical director. • Care Coordinator/ Community Health

Navigator. • Member/family. • AAA assessors/

coordinators. • Housing coordinator. • Pharmacist. • Behavioral health. • Other community

agencies.

Member-centric

Facility-based care

Model of Care — How the Model of Care Creates a Single Point of Contact for the Member and Primary Care Physician to Achieve Coordinated Care

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1. Each member enrolls with a primary care provider/medical home.

2. An Initial Health Screen is completed upon enrollment.

3. A Comprehensive Assessment will be completed within 60 days of enrollment for moderate/high risk members or 90 days for low risk members. The screening and assessment are used to collect member information regarding:

• Physical and behavioral health history. • Preventive care. • Level of activity. • Medication use.

4. Care Team coordinates and arranges care for the member as needed.

5. An Individual Care Plan is developed which includes care and support from health care providers, community agencies and service organizations.

Model of Care — Plan Implementation Overview

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Model of Care Components

Prior authorization

Quality management

review

Case management

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Prior Authorizations — Benefits of Using Prior Authorizations

Prior authorization:

• Ensures the patient receives the right care for the right condition.

• Helps identify members who may not be engaged in the Care Management process.

• Provides a better picture for the Multidisciplinary Team, enabling them to develop comprehensive care plans.

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Partial List of Services that Require Prior Authorization and/or Organization Determination*

• Elective/non-emergent air ambulance transportation.

• All out-of-network service (excluding emergency services).

• Inpatient services.

• Certain outpatient diagnostic tests.

• Home health services.

• Therapy and related services.

• Transplants, including transplant evaluations.

• Certain durable medical equipment (DME).

• Religious nonmedical health care institutions.

• Hyperbaric oxygen.

• Surgery.

• Surgical services.

• Gastric bypass or vertical band gastroplasty.

• Hysterectomy.

• Pain management.

• Radiology outpatient services:

• CT scan.

• PET scan.

• MRI.

• For services not typically covered under Medicare, providers must still request an organization determination.

• * Exceptions apply. For a full list of services that require prior authorizations, please refer to the Provider Manual or call Care Management.

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• First Choice VIP Care Plus has up to fourteen (14) calendar days to complete a standard request for prior authorization and notify the provider of the organization determination.

• First Choice VIP Care Plus has seventy-two (72) hours to complete an expedited request.

• Providers have up to two (2) business days upon receipt of the organization determination to request a peer-to-peer review by contacting the Prior Authorization Line at 1-855-294-7046.

• Refer to chapters five (5) and six (6) of the First Choice VIP Care Plus Provider Manual or the Provider section on the First Choice VIP Care Plus website for more information.

Prior Authorizations -Time Frames

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• Once an authorization is processed, the First Choice VIP Care Plus provider will receive a phone call and a fax alerting him or her to the organization determination.

• If the request is partially or fully denied, the member receives an Integrated Denial Notice from First Choice VIP Care Plus , alerting the member of his or her appeal rights. Providers will also receive this notice for informational purposes.

• Please note - Providers may NOT use the Advanced Beneficiary Notice of Non-coverage (ABN) Form CMS-R-131 with Medicare Advantage plans.

Prior Authorizations - Organization Determination Process

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Success Stories

In the short time we have been active we are pleased to say we have had several member success stories due to the Model of Care process.

We would like to share some of those with you, so you can see the impact we are already having.

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“Ms. Smith”

When the First Choice VIP Care Plus community navigator first encountered one of our members who suffers from a rare brain tumor, the member had several concerns. They included being hungry, lack of transportation to and from her doctor’s appointments, the cleanliness of her home, and the inability to understand the importance of taking her medications.

The navigator started attending her appointments with her and assisted her with getting back on all of her medications. The navigator established a relationship with the member’s oncologist. The oncologist thanked the navigator for the dedication and compassion that First Choice VIP Care Plus has to offer.

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The navigator requested and was given a referral from the oncologist for home health to provide services to maintain her blood pressure and help her keep up with medications. The navigator also contacted the case manager for the Waiver services program, who quickly came out to visit the member. She immediately started receiving Meals on Wheels, in-home help to clean her home three days a week, and a raised toilet seat.

The navigator was also able to set up an appointment with a new PCP and a meaningful Multidisciplinary Team meeting was conducted. The same day, the member gave the navigator a notice from DSS which stated she did not return her Medicaid recertification and would be losing her Medicaid benefits. The navigator assisted the member with the recertification paperwork and took it to DSS where she asked to speak to a supervisor. The navigator spoke to her, explaining the member’s situation, medical condition, and that without Medicaid these services would not be available to her. The supervisor was gracious enough to recertify her that day. Both the navigator and the supervisor became overwhelmed and cried knowing they were able to help this member in a significant way.

“Ms. Smith” Continued

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“Lillian,” 75 years old, had moved from Florida to Hampton, South Carolina, to live near her mother. She had not visited a doctor for four years and didn’t have a phone where she lived.

When Latonia, a Community Health Navigator based at Select Health’s Charleston headquarters, was unable to reach Lillian by phone, she drove nearly 70 miles to her home and knocked on her door. Lillian welcomed Latonia into her home, and accepted her offer to help.

“Lillian”

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“Lillian said her knees hurt,” Latonia said. “She agreed to go to a doctor.” Latonia worked with Lillian to select a primary care provider and scheduled an appointment. At Lillian’s request, Latonia said she would visit the doctor with her.

During her visit, Latonia learned Lillian had other concerns. “I said, ‘Tell me your worries and I’ll see what I can do,’” Latonia said.

Lillian had more than $1,000 in overdue electric utility bills and her water heater was not functioning properly. Latonia contacted a social worker for assistance. The electricity bill was paid, and the landlord said he would install a new water heater.

“Lillian” Continued

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When Roxana, Community Health Navigator, visited “Ms. Robinson” at her home in Greeleyville, SC, the GPS for her address was not working properly due to a recent 911 county line re-distribution. Roxana drove around, as the address was not correct, and due to the rural area was not able to get a phone line out.

After numerous attempts to make contact, Roxana was finally able to reach Ms. Robinson’s daughter-in-law, Lurean, who asked Roxana to go to the nearest gas station and call her from there. Lurean drove 10 miles to meet Roxana and then they drove another 10 miles to get to Ms. Robinson’s home.

“Ms. Robinson”

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After meeting with Ms. Robinson and her family it was obvious she had some very special and urgent needs. She was very grateful that First Choice VIP Care Plus “had sent someone who cares about me all that way here”.

Ms. Robinson was in need of services such as, home modifications/repairs: leak in a sink, pest control, weatherization of her home, grab bars in a shower, assistance with her power bill, and information regarding re-application to SSI, as she missed the re-certification deadline.

Now that Care team is aware they are actively working to help her to meet all of these needs.

“Ms. Robinson” Continued