Presentation on theme: "1 Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004."— Presentation transcript:
1 Wisconsin Partnership Program Steven J. Landkamer Program Manager Wisconsin Dept. of Health & Family Services July 14, 2004
2 Wisconsin Has Implemented Health/ Long-Term Care Programs That: n Provide Comprehensive Health & Long-term Care to People Who Meet Nursing Home Admission Criteria & are Medicaid Eligible; n Allow Consumers to Retain Choice of Primary Care Physician; n Maximize the Ability of Consumers to Live in Their Own Home & Participate in Community Life.
3 Wisconsin Has Implemented Health/ Long-Term Care Programs That: n Improve Functional & Clinical Outcomes; n Engage Members in the Decision Making Process About Their Own Care; n Minimize Reliance on Institutional Care; n Reduce Costs by Lowering the Need for Acute Care Intervention by Providing Consistent Primary Care.
4 The People Served Are: Medicaid Eligible or Dual Eligible for Medicare and Medicaid Diagnosed With an Average of 12.7 Different Conditions Taking 13.7 Different Medicationson Average In Need of Skilled Nursing Intervention
5 Wisconsin Has Implemented Two Programs Fully Integrate Medicare and Medicaid Services Program of All-Inclusive Care for the Elderly (PACE) The Wisconsin Partnership Program
6 Key Distinctions Between Partnership & PACE PACE Members: Attend a Day Center & Receive Most Services There; Receive Care by the On-site PACE Physician; Are Elderly. Must Be Residents of a Large Urban Areas Capable of Supporting a PACE Site.
7 Key Distinctions Between Partnership & PACE Partnership Members: Select a Primary Care Physician From a Contracted Provider Network; Receive Most Services in Their Home; Can Be Frail Elderly or Have a Physical Disability; The Partnership Nurse Practitioner Serves As Team’s Primary Care Representative & Accompanies the Member to Most MD Appointments; Partnership Works in Both an Urban & Rural Setting.
8 Funding for Partnership & PACE Both Medicare and Medicaid Benefits are Capitated and Paid to the Contractor The Medicare Capititation is the Rate Book Multiplied by a 2.39 Risk Adjuster. (90%in 2004) Risk Adjusted Rate Based on CMS-HCC and Frailty Adjuster (10%in 2004) The Same Rate Setting Methodology is Used for Both PACE and Partnership
9 Funding for Partnership & PACE Medicaid Capitation is Calculated by Discounting a Blended Average Cost for Nursing Home Care and Home and Community Bases Waiver Programs Costs. Rates are Risk Adjusted for Age, Medicaid Only or Dual Eligible Status, and Level of Care. The Rates for Elderly and People with Physical Disabilities Differ Significantly. The PACE and Partnership Rates Differ Slightly Based on Case Mix
10 PMPM Comparison--Average WPP & January 1999 Waiver Population
11 How Partnership Works Wisconsin Contracts with 4 Community Based Organizations to Provide Partnership Managed Care. Elder Care of Wisconsin Community Living Alliance Community Care Organization Community Health Partnership
12 How Partnership Works
13 How Partnership Works Partnership Organizations are at Full Risk for All Health and Long-Term Care Outcomes. Both Medicare and Medicaid Capitation Payments are Made to the Organizations. The Partnership Organizations Subcontract with Various Providers including Primary Care Physicians and Hospitals and Pay Them on a Fee-For-Service Basis
14 How Partnership Works Care is Coordinated Through an Interdisciplinary Team which includes: The Member Primary Care Physician (PCP) Nurse Practitioner (NP) Registered Nurse (RN) Social Worker
15 How Partnership Works The NP Meets with the PCP to Establish a Collaborative Practice Agreement that Often Leads to the Delegation of Primary Care to the NP. The NP Acts as the Liaison Between the PCP, the Member and the Remainder of the Team. RNs Provide Both Care Management and Skilled Nursing Care. Social Workers Provide both Psychosocial and other Supportive Services as Necessary
16 How Partnership Works Provides Prevention Services to Minimize the Need for Inpatient and Emergency Room Care. Provides Community Based, Supportive Services to Minimize the Need for Nursing Home Care. Accompanies the Member to Physician Visits and “Translates” Physician Recommendation for the Benefit of the Member and the Team.
17 How Partnership Works Assures that Member Concerns and Preferences are Understood. Assures Follow Through with Physician Recommendations. Promotes Quality of Life by Supporting Member Specified Outcome.
18 Measuring Outcomes of the Partnership Program The Department of Health and Family Services is using several methods, both traditional and innovative, to measure quality & effectiveness: 14 Member Outcomes Based on Member’s Input about his/her Quality of Life; Incidence of ACSCs (ambulatory care sensitive conditions); Utilization of Inpatient Hospital & Nursing Home Care Before & After Partnership.
19 14 Member Outcomes Developed by the Council on Quality and Leadership, a national accreditation agency for community disability programs. Determines whether: members’ desired outcomes are being met, and the support the member needs to achieve the outcome has been put in place by the team.
20 Member Outcomes
21 Self-Determination & Choice Outcomes
22 Self-Determination & Choice Supports
23 Health Care Outcomes Staff Compile & Trend Data On Hospitalizations For Ambulatory Care Sensitive Conditions (ACSC): ACSCs are defined by the Institute of Medicine as conditions for which good access to primary care should reduce the need for hospital admissions. n
24 Result: Hospital Admission The Rate of Hospital Admissions for Ambulatory Care Sensitive Conditions Decreased by 41.1 % from 2000 to 2002.
25 Result: Hospital Admission
26 Result: Hospital Admission
27 Result: Access to Dental Care Access to Medicaid funded dental care remains difficult in Wisconsin. For example: 17% of home and community-based waiver programs’ for elderly and people with physical disabilities had dental visits in % of all participants in PACE and Wisconsin Partnership program had dental visits in 2001.
28 Result: Health Care Utilization u Using the Hospital Discharge Data Base, Staff are Able to Demonstrate Pre/Post Enrollment Hospital Utilization u Findings Show a Positive Reduction of Inpatient Hospitalization & Nursing Home Use
29 Comparing Hospital Use, Same People Before & After Enrollment
30 Comparing Nursing Home Use, Same People Before & After Enrollment
32 Physician Satisfaction Survey Completed in April 40 % of Surveys Returned Statistically Significant 95% Confidence Level
33 Physician Satisfaction
34 Physician Satisfaction
35 Physician Satisfaction
36 Areas Needing Improvement Member, Quality of Life, Outcomes. Further Impact on the Incidence of Hospitalizations for ACSC. Comprehensive Evaluation. Demonstration of Cost Effectiveness. Provider Satisfaction. Interventions in Cases Where there is Mental Heath and/or Chemical Dependency Concerns.
37 Areas in Need of Improvement
38 Areas in Need of Improvement
39 Areas in Need of Improvement
40 Conclusion Partnership offers a viable alternative to PACE that can be applied to people with physical disabilities and people who live in a rural setting. Partnership effectively delivers member- specified outcomes. Partnership is demonstrating positive health care outcomes.