1. Knowing Our Market SoCal Home and Care Network

2. Target Populations Dual eligibles Medicare FFS patients ACO members/patients Adults with chronic conditions Mental Health Post-hospital – Psych Homeless Medicaid/uninsured Veterans/VA Caregivers/family members At risk of SNF placement/LTC LT Acute Care patients - a la Kindred – up to 21 days

3. Target populations – Characteristics & Needs Frequent 911 In dialysis – ESRD – non-emergency medical transportation Newly diagnosed, ready for self-management in diabetes, chronic pain, cardiac Dementia: Their caregivers need support Non-medical support services Homebound – need meals, etc. Multiple chronic conditions with functional impairment EOL(ish) – palliative care, hospice, advance care planning, supportive wraparound services 3 WE ARE NOT MEDICAL. We are not competitive with home health

4. Target Populations - Needs Frequent 911: Self-care/self-management; psychosocial; anxiety treatment/plans; access to primary care & urgent care; transportation In dialysis – ESRD – non-emergency medical transportation Newly diagnosed, ready for self-management in diabetes, chronic pain, cardiac – Evidence-based programs Dementia: Their caregivers need support Non-medical support services Homebound – need meals, etc. Multiple chronic conditions with functional impairment EOL(ish) – palliative care, hospice, advance care planning, supportive wraparound services Aging with DD – regional center type of services post-21 4

5. Customer Groups Measurable high value outcome(s) we produce for customers Stable community living Appropriate use of healthcare services – Lower utilization – reduced acute & SNF Appropriate use of HCBS Fall prevention Safe environment Diabetes management Better health Better self-care & self management Less pain, more energy, sense of safety Patient-centered/directed – goals reassessed and care plan adjusted

6. Customer Groups Our next step(s) to further develop the customer profile and test need Data about needs of people – In-home assessment of post-hospital older adults: 66% had med needs; 70+% with home safety, depression, etc. issues – Is CCTP basically the same population? Let’s do a random sampling effort to determine the level of need using HomeMeds & other intake instruments…invest in producing the data we need. – Identify what data needs to be collected – Use for planning & marketing – Pull data from CCTP quarterly reports – ASK Lewin – Get caregiver information, too. – Gap analysis on data access – use MSSPCare, SAMS, whatever 6

7. Contracting Organization (CO) First/Next Name/Type of CO Hospitals at risk of penalty – Map hospitals across counties Hospital systems – Map hospital systems in our service area – GET FROM QIO Health Plans Physician groups SNF CVS – MTM/CMR Medi-Cal plans Key CO person for contracting CareFirst – Pam Mokler Health Net – Martha Santana- Chin & the gang Their mission and major interest/need Hospital system – Reduce penalties – If in ACO – risk and shared savings – Revenue SNF – penalties for sending patients back to help Specific HCOs: Prospect – Steve O’Dell CalOptima – MSSP lookalike

8. Contracting Organization (CO) We Will Pursue First/Next (e.g., health plan, ACO, health system, etc.) Our next step(s) to further engage the CO Relationship Value proposition Menu for MCO – Service lines/description What we do that they are not doing – TRANSLATE Pilot with a case rate, QI cycle & document findings & outcomes 8

9. Policy or regulatory conditions to address? Are there any policy or regulatory conditions that your network will need to meet or change in order to secure a contract? If so, what are they? ACL get Office Duals to set requirements for stakeholder involvement and inclusion of Aging/Disability Network – protect their investment in the system State-level ditto – require inclusion of our networks IT - ACL & ONC – Group group-purchasing discounts for IT systems Legal standing – Prototype legal structures Consolidate all of these efforts and convene national-level group of plan leaders to educate them and connect the dots about Aging/Disability Network – Definition of quality Get us on the agenda for national & state conferences – Toolkit for target groups – about our value, structure, services, etc. HIPAA & state survey coverage/language

10. Champions Who can endorse our network and open doors for us? C-suite in health plans & hospitals – Someone who is credible Board members Associations – CAHF – LeadingAge Consumer advocates ACL/CMS National advocate? – Molly Coye, Atul Gawande 10

11. Competition and Forces We Need to Address Our primary competitors are: Homecare agencies – the Home Instead Make vs. buy Commercial people – prepackaged meals providers 11

12. Competition and Forces We Need to Address Major sources of inertia we must overcome: IT/technology/data Knowing where to start Tired… Perfectionism 12

13. Competition and Forces We Need to Address Competitors’ Advantage Resources IT Full coverage – national company – Track record in large markets Assets Can take risk Our advantage Feet on the ground Experience in people’s homes Cultural competence Home, home, home

14. Insights Our biggest insight(s) from this session on Knowing Our Market is/are… LTAC/SNF market potential Educate MCO Leaders about A/D network – Conference?? White paper?? – Compelling voice to write a compelling thought piece aimed at the visionaries in health plans – START AT THE TOP We need to focus on national buying power for IT Consistent product lines would help us come up with toolkits for everyone – IT – Marketing materials We know we are already preventing healthcare utilization

15. Action Steps The action step(s) we will take in the next month to engage our market are: Meet with high-readmission hospitals to promote members’ care transitions Product definition discussions with Health Net, CareFirst, Kaiser Continue to solidify our alliance – Set up a structure workgroup Develop collateral & business case statements for care transitions for different payers/purchasers Develop pricing – it will vary by: – Volume – Network extent 15

16. Parking Lot (Issues for later, additional questions for speakers) List here 16