Presentation on theme: "Health Homes: What Are They and What Might They Look Like"— Presentation transcript:
1Health Homes: What Are They and What Might They Look Like Harvey RosenthalNYAPRS Annual ConferenceSeptember 14, 2011
2Goals of Our Presentation To raise awareness and get your feedback about:what a health home is and why they have been developedhow they will change how some Medicaid beneficiaries get their health and mental health carehow they will effect service providersTo discuss examples of what health homes might look
3Health Homes are about Medicaid Medicaid pays for health services for Americans with low incomes and resources.It is funded by the state and federal governments and is managed by the states.People with disabilities represent a large number of Medicaid beneficiaries.Medicaid is the largest source of funding for medical and mental health and substance use health-related services for New Yorkers.
4Why are Changes Coming to Your Medicaid Healthcare? US and New York state budgets can no longer keep up with Medicaid’s rising costsAt the same time, too many Medicaid beneficiaries don’t get or participate in enough of the right kind of healthcareAs a result, too many spend too much time in expensive visits to emergency rooms and hospitals
5Health Homes 101Health homes are a new way to structure how Medicaid health, mental health and substance use services will work together to deliver coordinated services to beneficiaries with ongoing (‘chronic’) conditionsTheir goals are to help improve the health of beneficiaries while saving money for the state and federal governments
6Health Homes 101These homes are not residences or buildings….they are a network of care providers led by one lead group that will take primary responsibility to make sure your healthcare needs are understood and met.That lead provider and that network is supposed to provide you a safe and responsive ‘home’ for your healthcare needs
7How are Your Mental Health Needs Addressed Now? Emergency Services (diversion) Inpatient Services (diversion) PH CDT Clinic IPRT PROS Clubs Employment Peer Services Recovery Ctr ACT Case Management Housing
8What About Your Other Healthcare Needs? Emergency Services/Urgent Care Hospital Services Primary doctor/nurse practitioner Specialists for teeth, heart, lung, feet, diabetes and so forth….. Substance use treatment/detox
9Uncoordinated Services Result In… Many different treatment plans with no one knowing what the other is doingMissed opportunities to make the right diagnoses and provide the right treatmentWrongful and/or too many medicationsHuge costs
10Uncoordinated Services Result In… Confusion and fearLoss of hope for improvement and wellnessDiscouragement for self careOver/under treatmentNo one person to help explain it all (health literacy) to you, bring the treatment providers together and explain you to them
11The U.S. has a Sick Care System not a Health Care System Half of Americans have one or more chronic health conditions (155+ million)Over half of these people receive their care from 3 or more physiciansIn total, treating chronic health conditions consumes 75%+ of the $2.5 trillion we spend on healthcare each year in the U.S.In large part due to the fact that money doesn’t start flowing in the US healthcare system until after you become sick"Chronic conditions in childhood are common and dynamic, underscoring the benefits of continuous, comprehensive health services for all children to adjust treatment of chronic conditions, promote remission, and prevent onset of new conditions. Future research should examine etiological differences between persistent and remitted cases," the authors conclude. (JAMA 2010;303: Available pre-embargo to the media at www.jamamedia.org)
12America’s Healthcare System at the Brink “The American healthcare system is a dysfunctional mess.” (Ezekiel Emanuel, MD, Chair of the Department of Bioethics at the Clinical Center of the National Institutes of Health)$2.3 - $5.2 Trillion“As much as 30% of health care costs (over $700 billion per year) could be eliminated without reducing quality”: Big focus for Nat./State Budget Cutters
13Big Stakes for Our Community We’re among the sickest disability groups, dying 25 years earlier than the general public.Compared to non-Hispanic whites with SMI, African Americans and Latinos with major MH diagnoses face serious health inequities due to:Higher rates of obesity, diabetes, metabolic syndrome, and cardiovascular diseasePoorer access and quality of medical care
14NYS Backdrop: High Cost of Medicaid Care for New Yorkers w/ Multiple ‘Chronic’ Conditions New York’s Medicaid program serves almost 5 million beneficiaries at a cost of over $50 billion annually.20% of Medicaid beneficiaries (1,029,621 ) account for 75% of the program’s expenditures: $31.1 millionAverage cost per year: $30,195 which is 15 times higher than the average beneficiary
15NYS Backdrop: High Cost of Medicaid Care for New Yorkers w/ Multiple ‘Chronic’ Conditions These beneficiaries have “multiple co-morbidities, are medically complicated and require services across multiple provider agencies. Due to their multiple and intensive needs, their care can often be fragmented, uncoordinated and at times duplicative. “Over 40% of these beneficiaries are diagnosed with mental illness and chemical dependency.
16NYS Ranks 50th in Avoidable Hospital Readmissions NYS Department of Health estimated that $800 million was spent last year on ‘avoidable Medicaid hospital readmissions.’70% of these involved beneficiaries with mental health, substance use and major medical conditions.65% of admissions for this group were for medical reasons.Latest estimates rise to $1.4 billion
17Health HomesNY health homes are multidisciplinary teams comprised of medical, mental health, and chemical dependency treatment providers, social workers, nurses and other care providers.The team will be led by a dedicated care manager who will assure that enrollees receive all needed medical, behavioral, and social services in accordance with a single care management plan.
18Heath Homes GoalThe health home provider will be accountable for reducing avoidable health care costs, specifically preventable hospital admissions/readmissions, skilled nursing facility admissions and emergency room visits and meeting quality measures.
19Core Health Home Services Care ManagementCoordination And Health Promotion;Transitional Care;Patient and Family Support;ReferralsUse of Information Technology (IT)
20Health Home Network Leader Health home providers can either directly provide, or subcontract for the provision of, health home care coordination services.The health home provider remains responsible for all health home program requirements, including services performed by the subcontractor.Health homes coordinate services to network partners who continue to bill Medicaid
21Health Home Network Requirements Preferred health home applications will include an integrated health care and community provider network that includesmanaged care planshospitalscommunity based organizations,targeted case management providersmental health and substance abuse services providers.
22Health Home Provider Network Medical care providers: primary care, ambulatory care, preventive and wellness care, FQHCs, clinics, specialists including HIV/AIDS providers, hospitals, rehabilitation/skilled nursing facilities, pharmacies/medication management services, home health services, chronic disease self-management and patient education services, etc.
23Health Home Provider Network Behavioral health care providers: acute and outpatient mental health, substance abuse services and rehabilitation providers, etc.); andCommunity based organizations and social services providers: TCMs, public assistance support services, housing services, etc.
24HH Program Requirements Coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge;Language access/ translation capability;24 hour 7 days a week telephone access to a care manager;
25HH Program Requirements Crisis intervention;Links to acute and outpatient medical, mental health and substance abuse services;Links to community based social support services-including housing;Beneficiary consent for program enrollment and for sharing of patient information and treatment.
26Electronic Healthcare Records Health homes will be using health information technology to link services, facilitate communication among team members and between the health team and individual and family caregivers
27Health Home Priority Groups The State will provide health home providers a roster of assigned enrollees and current demographic information to facilitate outreach and engagement.The roster will include peoplefrom clinical risk groups (CRG),who are predicted to be re-hospitalized based on state algorithmswith major behavioral health conditions (100k with SPMI only, most with co-occurring conditions)
28Health Home Priority Groups HH priority groups at program roll out will be groups who are “least engaged” in case management, medical, mental health and substance use treatment services and those who have high acuity scores.”
29Auto-Assignment, Opt-out Medicaid enrollees will receive letters, assigning them to a health home provider based, “to the extent possible, on existing relationships with health care providers or health care system relationships, geography, and/or qualifying condition.”
30Auto-Assignment, Opt-out Once assigned, enrollees will be given the option to choose another provider when available, or opt out of health home enrollment.Health Homes will be urged to engage/retain enrollees. They expect good engagements to lead to high retention rates.Pending federal approval, enrollment in the Health Home will be mandatory with opt out provisions.
31Draft Patient Flow 860,000+ high cost/high need Medicaid enrollees 31 (1) Chronic conditions at risk for a 2nd chronic condition(2) Chronic conditions(1) Serious & Persistent Mental Health Condition*Medically and Behaviorally ComplexNon-Compliant with Treatment Health Literacy IssuesADL StatusInability to Navigate Health Care SystemSocial Barriers to CareHomelessnessTemporary HousingLack of Family or Support System Food , IncomeNeed assistance applying for Entitlement ProgramsYesDraft Patient FlowPatient Meets Health Home CriteriaAssigned a Health HomePatient Assessment*Level I Health Home Services – Moderate NeedLevel II Health Home Services – Multiple Complex NeedsLevel III Health Home Services – Intensive Complex NeedsPeriodic Reassessment * for continuation of Health Home ServicesPrimary Care Practitioner ManagesHealth Home Services Not Required31
32Key Roles for TCM, Housing, Supports Inclusion of TCM programs (including OMH and HIV/AIDS COBRA TCMs, and Managed Addiction Treatment Services Providers (MATS)), housing and other community based organizations is “strongly encouraged.”Beneficiary assignment to health homes will partially be based on an organization’s network capacity.
33Tiered Case Management Plan A strong plan to deploy tiered care management plan for:Low need- stable individuals in ambulatory care with episodic crisis or inpatient needIntermediate need individuals- not as connected to ambulatory care, more frequent emergency room and inpatient useHigh need individuals- such as those serviced by OMH and HIV/AIDS COBRA TCMs and the MATS program.
34From Case Management to Care Management Care managers will have more responsibility and authority to coordinate a broader array of healthcare (e.g MH, SU, medical conditions)They will be able to do more than ‘assess, link and monitor’, e.g. transportation, individualized supportMore slots will be needed beyond existing case management/MATS to serve 900,000 health home eligible beneficiaries.
35Big Potential Role for Peer Services Health Homes are encouraged to utilize peers as part of their multidisciplinary team, especially with activities relating to patient and family support and utilization of community and social support services.
36Expected Impact on Beneficiaries Most people will likely be auto assigned into health homes that include their case management program and providerMore attention, help needed to protect beneficiary rights and choicesYou will likely be asked to participate in fresh new health/BH assessments and to help shape new goal and treatment plans
37Expected Impact on Beneficiaries Health home coordinators will have and share with provider systems up to date information about beneficiaries’ past and current health issues, their providers and their response and follow up with medications and treatmentsUnmet needs will be identified and referrals will be made and coordinated to new or ‘better’ health care providersEveryone will be focused on averting avoidable ER and hospital visits.
38Financial Pressures, Healthcare Reform Can Speed the Pace of Wellness and Recovery Promotion… If we do more than simply save dollars by diverting people from ERS and hospitals and are successful…at truly helping people meet their health and personal goals via a more responsive and person directed health care and supports
39Or Are We Back to the Medical Model? We have helped advance mental health systems by infusing recovery, rehabilitation, rights and peer support approaches and values.In integrating with the healthcare system and its illness, medication and patient based emphases, we must be strong and persistent in infusing these values into those systems by demonstrating that they need us and them to succeed.
40Changing Timelines, Trends Health Homes Letters of Intent now due September 7 due to Hurricane Irene.Health Homes Application due October 5Health Home start up: November 18 quarters of federal 90% Medicaid share beginsPayment to health homes beginChildren will not be included in first round
41NYAPRS Regional Forums Syracuse September 27th: 10:00am - 1:00pm Hutchings Psychiatric CenterWestchester - White Plains October 4th: 10:00am - 1:00pmLong Island – Amityville October 9th: 10:00am - 1:00 PmBuffalo October 12th: 11:00am - 2:00pmRochester October 13th: 10:00am - 1:00pmPoughkeepsie October 20th: 10:00am –New York City – October 21Capital District - Albany: October 26North Country - Date And Location Tbd