Transcript PPT - CalDuals.org

COORDINATED CARE INITIATIVE
QUARTERLY STAKEHOLDER MEETING
JULY 10, 2014
Pamela Mokler, Vice President, LTSS, Care 1st
Vicki Macedo, Program Specialist, HHSA AIS
Mark Sellers, Asst. Deputy Director, HHSA AIS
COUNTY OF SAN DIEGO
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Health & Human Services Agency
 Aging
& Independence Services
 Behavioral
 Children’s
 Public
Health Services
Services
Health Services
 Self-Sufficiency
 Support
Divisions
AGING & INDEPENDENCE SERVICES
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Area Agency on Aging/ADRC
Adult Protective Services/Senior Mental Health Team
In Home Supportive Services
Multipurpose Senior Services Program ( & “MSSP-Like”)
Long Term Care Ombudsman
Call Center
PA/PG/PC
Veteran Services
Senior Nutrition
Community Services – IG, CM, RSVP, Health Promotions
Community-Based Care Transitions Program
SAN DIEGO CCI HEALTH PLAN OPTIONS
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AB 1040- CA Long Term Care Integration Pilot Project (LTCIP) –
Planning Committee formed 1999 with the following mission:
“Develop a comprehensive, integrated continuum of acute and
long-term care (health, social, and supportive services) for the
aged, blind, and disabled (ABD).”
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Began with 50 participants – now over 800 members strong:
Multiple Medical, Behavioral Health, Social Service Providers,
Consumers, Caregivers and Advocates
ADRC
www.sdltcip.org
Communitybased Care
Transitions
Program
LTCIP
CCI
Advisory
Committee
San Diego
Network
of Care
SAN DIEGO CCI ADVISORY COMMITTEE
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Cal MediConnect Health Plans established to
provide them recommendations about operations,
access to services, outreach & education, etc.
 Communications
Sub-Group: coordinated
outreach to consumers, providers, physicians,
pharmacists, hospitals/clinics, etc.
 Coordination
Guide Sub-Group: coordination
between the Health Plans & IHSS/PA & MSSP
SAN DIEGO CCI ADVISORY COMMITTEE MEMBERSHIP
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Cal MediConnect Health
Plans
HHSA/AIS
Public Authority
Dual-eligible consumers
Hospital Association
SD Medical Society
Consumer Center
HICAP
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CBAS
PACE
Advocates
Community Clinics
HCBS Providers
SNF
Harbage Consulting Firm
Behavioral Health
Disability Rights
IHSS COORDINATION GUIDE DEVELOPMENT
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Workgroup: All 5 Health Plans, AIS IHSS
Managers/Program Staff, Public Authority
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Commitment: A single protocol
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CCI Advisory Committee: review & approval
HEALTH PLAN PERSPECTIVE
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IHSS is a core service that is needed to keep
members with ADL/IADL deficiencies living in the
community
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We need to make it easier for our members to
transition from hospital to home with IHSS
services, than it is to transition from a hospital to a
SNF! – especially on a Friday evening! We need
expedited IHSS assessments and extended hours.
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All IHSS recipients’ needs are not the same!
Programs need to be FLEXIBILE to meet changing
needs of members/clients.
IHSS COORDINATION GUIDE KEY ELEMENTS
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Application Process flow chart – especially
helpful for the Health Plans at the beginning of
the process
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Call Center and Web Referral processes – giving
them the contact information they would need
and letting them know what type of information
they will need to provide on referrals.
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The establishment of “expedited” referral criteria
and the development of an “expedited” referral
process
IHSS COORDINATION GUIDE KEY ELEMENTS
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Differentiating between “expedited referrals” and
situations where “urgent service referrals” are
appropriate
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Explaining form requirements and how the Health
Plans may play a key role in assisting the member
with this
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Providing phone numbers to each district office, as
well as a zip code list of which office handled
which zip code, so that Health Plans could contact
the clerical staff at each office with questions.
EXPEDITED IHSS APPLICATIONS
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Expedited applications will be processed within
10 business days of receipt by the IHSS Social
Worker. Health Plans will be contacted if there
are problems that prevent or delay the process.
Examples could include but are not limited to
the following:
 Refusal
 Failure
of services by the Health Plan Member
to cooperate or provide required information
EXPEDITED CRITERIA
Someone who has critical care
needs and:
 No one is available to
provide in-home care
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Is unsafe in his/her own
home
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Is at risk of
hospitalization (or rehospitalization) without
additional assistance
Someone who has critical care
needs:
 That cannot be fully met
without additional
assistance from IHSS
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Is unsafe in his/her own
home
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Is at risk of
hospitalization (or rehospitalization) without
services in place
ADDITIONAL EXPEDITED INDICATORS
Other indicators for an expedited referral could include:
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A diagnosis of a terminal illness.
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A rapid decline in health.
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Client Is transitioning out of a hospital, and no one is
available to provide in-home care or the care needs can’t
be fully met.
If necessary the IHSS Social Worker may conduct a needs
assessment in the hospital. Once the Member transitions
home, the IHSS Social Worker must complete an in-home
needs assessment within 10 business days from the date of
discharge.
APPROVAL/DENIAL ON EXPEDITED APPS
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A Notice of Action (NOA) will be issued providing
information on services and the number of
hours authorized, or the reason for any denial
of services
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IHSS will inform the Health Plan of any
ineligibility to IHSS services
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The client has 90 days from the date of the
Notice of Action to file an appeal
HEALTH PLAN PERSPECTIVE: IMPORTANT ACCOMPLISHMENTS
AIS was willing to be flexible
 AIS was willing to expedite referrals for Plan
members transitioning from hospital or SNF to
home
 Agreement from all 5 Health Plans, Public
Authority and AIS on a single, core protocol
 Shared value for the consumer-driven
foundation of the IHSS program
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CCI IMPLEMENTATION CHALLENGES & OPPORTUNITIES
Partnerships/relationships are everything!!
 Broad coordination is critical!
 Training, re-training…and more training!
 Slow beginning for IHSS – applications (standard
and expedited) and CCT’s – Why?
 Continuous efforts at delivering information and
resources to consumers & IP’s
 HICAP/Consumer Center for Health Education &
Advocacy calls – steady, but settling, burst at start
of the month
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