1. Optum’s Role in Mycare Ohio

2. What is MyCare Ohio?
New opportunities generated by the Affordable Care Act have allowed Ohio to implement the MyCare Ohio program.
MyCare Ohio is a demonstration project that integrates Medicare and Medicaid services into one demonstration waiver, operated by a Managed Care Plan.

3. Comprehensive, Team Based, Person Centered Approach

5. Overview of Optum Resident
Optum, a health services company, partners with insurance companies to bring specialized clinical support and provider relations expertise to skilled nursing facilities
Optum provides a patient-centric, treat in place clinical model led by clinicians to coordinate and enhance the quality of care for nursing home residents.
Optum Nurse Practitioner
Family/Responsible Party
Health Plan
Optum Medical Director
Resident
Activities Director
Primary Physician
Facility Administrator
Director of Nursing
Social Services
Business Office

6. Optum Clinical Process
Intensive Delivery of Primary Care
Onsite Clinician
Treat in Place
Our clinical team delivers care in conjunction with the PCP and the facility staff.
Evaluates and manages the care of enrollees in conjunction with the family, Trans-Disciplinary care team, and any involved specialties. The NP (or PA) also provides onsite formal & informal education to facility staff. RN or LPN assists NP in the development and implementation of the Care Plan.
Identify and treat a patient’s change in condition early by providing appropriate medical management, prevents unnecessary hospitalizations.

7. Program Overview: Full MyCare Ohio Clinical Model (Opt-In)
Population
Long-term stay Beneficiaries who are covered for both Medicaid and Medicare services (“Engaged Members”)
Who is delivering the program?
Optum NP
Conducts Clinical Assessment
Orders diagnostic and laboratory tests
Orders pharmacological and non-pharmacological therapy and treatment
Manages the medical care of the patient in collaboration with the PCP
Optum RN
Develops the Comprehensive Assessment and Care Plan
Coordinates communication with the family and the responsible party of the engaged member
Coordinates Services for the engaged member, i.e. Transportation
Coordinates with the Health Plan on appropriate benefits
Optum LPN
Contribute to the completion of the Comprehensive Assessment and development of the Care Plan

8. Program Overview: Full MyCare Ohio Clinical Model (Opt-In)
What will Optum do? (In addition to Medicaid Model)
NP will make scheduled and unscheduled visits to medically manage the patient
A comprehensive medication review with the goal of reducing high risk medications.
Identify Outpatient Services (including Psychiatric) that may be required
Hospitalization follow up to ensure a smooth transition back to the SNF and visit with member. Visit includes a new Comprehensive Bi-Psycho-Social Assessment, medication review, and hospital order review.
NP will recommend members to be reviewed by Trans-Disciplinary Care Team for Hospice eligibility.
Benefits and Goals of the Program
Support patients and partners through coordinating/providing an improved quality of services and care
Improve performance on relevant HEDIS, HOS, MDS and other prioritized quality indicators, including Star ratings.
Support patient safety
Support Healthcare quality and affordability through continuous quality improvement as a core competency.
Improve efficiencies supporting quality initiatives.
Expedited diagnostic test results
Meet State, Federal, and regulatory requirements for model of care and quality improvement

9. Program Overview: Medicaid Clinical Model (Opt-Out)
Population
Long-Term stay MyCare Beneficiaries who are covered for Medicaid services
Who is delivering the program?
Optum LPN
Contributes to the completion of the Comprehensive Assessment and development of the Care Plan
Coordinates communication with the family and the responsible party of the engaged member
Coordinates Services for the engaged member
Optum RN
Develops the Comprehensive Assessment and Care Plan
Coordinates Services for the engaged member, i.e. Transportation
Coordinates with the Health Plan on appropriate benefits

10. Program Overview: Medicaid Clinical Model (Opt-Out)
What will Optum do?
Complete the Comprehensive Assessment
Update the Comprehensive Assessment as appropriate or as dictated in the 3-way agreement
Develop and maintain the Care Plan
Complete assessment for repatriation as appropriate and communicate results to our Health Plan partners and trans-disciplinary team for further action
Maintain the minimum contact schedule outlined in the 3-way agreement
Benefits and Goals of the Program
Provide improved Comprehensive Care Management and communication
Identify appropriate individuals who would be good candidates for repatriation
Identify candidates for appropriate additional services (i.e. Behavioral Health)
Coordinate with Health Plan Case Managers as appropriate
Disease management education for the patient
Enhanced communication with the family

11. Program Overview: Repatriation
Population
Long-term stay MyCare Beneficiaries who are covered for Medicaid services and those that are full MyCare Ohio participants (“Engaged Members”)
Program Focus: Identify members who are potentially eligible for repatriation, Optum will not be responsible for the actual transfer
Who is delivering the program?
Optum LPN/RN
Completes the Repatriation Assessment
Coordinate with Health Plan Care Manager
Coordinates communication with the family and the responsible party of the engaged member

12. Program Overview: Repatriation Program Goals
Identify good candidates for repatriation
Remain compliant with State and Federal requirements
Develop plan and process for discharge

13. Program Overview: Post Acute Skilled (PAS)
Population
Short-term stay MyCare Beneficiaries who are covered for both Medicaid and Medicare services (“Engaged Members”)
Who is delivering the program?
-Sees the enrolled patient after SNF arrival, and a progress focused note is completed
-Develops an initial plan of care upon admission and address Advance Care Directives and health care proxy
-Makes initial contact within 48 hours of admission to the SNF with follow-up visits occurring as needed until discharge
-Collaborates and Coordinates with the Trans –Disciplinary Care Team to proactively monitor patients’ skilled care and progress towards rehab goals and prevent hospital readmission
-Provides first call coverage
-Ensures accurate diagnosis coding to assist RAF improvement
-Writes a final progress note on each enrolled patient and sent to the patient’s Primary Care physician upon SNF discharge
-Coordinates with the Trans-Disciplinary Care Team to notify waiver services in the event of additional required services to aid in the transition back to community
Optum NP

14. Program Overview: Post Acute Skilled (PAS)
What will Optum do?
NP will make visits to the patient while they are in short stay/rehab
Visits will focus on preventing re-hospitalization, managing length of stay appropriately and returning the patient home with a medical plan of care
Optum RNs and LPNs will work in collaboration with the NP and the Trans- Disciplinary Care Team to coordinate communication and services
Benefits and Goals of the Program
Prevent unnecessary re-hospitalization
Manage length of stay with a goal of less than 20 days
Improve Quality Ratings
Work with the TCT to support and help coordinate the patient’s transition to home

15. Q & A

16. Thank You