1. Lifemark Long Term Care Experience December 15, 1999

2. The Lifemark Mission n Through innovative care management services and technology offerings, Lifemark strives to create fundamental change in the well being of vulnerable, frail, elderly and chronically ill people.

3. Locations Phoenix, AZ (Corporate Office) Albuquerque, NM Fort Smith, AR Honolulu, HI Houston, TX Indianapolis, IN Lansing, MI San Diego, CA

4. LIFEMARK CORPORATION Care Management Strategies for “At Risk” Populations December 1999

5. Aging Population Longer Life Expectancies Prevalence of Chronic Conditions Complex Benefit Coordination Why is Long Term Care (LTC) a heightened issue?

6. The Coordinated Model Integrated Services n Long Term Care n Home and Community Based Services n Behavioral Health n Medical Care Services: l Inpatient/Outpatient care l Physician l Lab/Radiology l EPSDT l Transportation l Ancillary Services l Specialist l Pharmac y l DME l Therapies “Single Entity” LTC HCBS Behavioral Health Medical Care Svcs n Coordinated Medicare fee-for-service and/or Medicare HMO Benefits

7. Coordinated LTC Model Full Continuum of Placement Options Most Restrictive Least Restrictive Assisted Living/ Residential Care Adult Foster Care Home Adult Care Home Home or Apartment Specialty Unit within a nursing facility Skilled Nursing Facility

8. Patient Centered Care Case Manager’s Role n Nurses, Social Workers, or those with 2 years case management experience n Coordinator, facilitator, investigator, service broker, liaison, and advocate who is empowered to authorize and verify services n Leads team of decision makers Patient Family or Representative Case Manager PCP n Closely linked to PCP, patient and family

9. Care Management Systems Initial In-Depth Assessment n Highly automated using laptop computers n Performed within five days of enrollment n Current/previous medical status n Socioeconomic profile n Psychological assessment n Functional assessment (ADLs) n Develop multiple alternative care plans for service(s), placement, provider, and/or reassessment schedule n Level of care determination n Perform cost effectiveness study n Initiate/authorize: l Formal service plan l Actual placement l Establish measurable goals Care One

10. Care Manager Scope of Authorization n LTC Services/Placements include n Nursing Facility n Assisted Living/Personal Care Home/Adult Foster Care n Adult Day Care n Community based alternatives n Medical Supplies/DME n Value Added Services n Home Services n Personal, Attendant, and Chore Services n Skilled Home Health Care/Short term therapy n Emergency Response Systems n Meals on Wheels n Respite

11. Patient-Centered Care Critical Elements to Success n Develop intense, fully integrated care management system to consolidate funding, limit fragmentation/duplication, monitor quality, outcomes, clinical utilization and costs n Establish an HCBS infrastructure and expand covered services to include full menu of HCBS services n Perform outcomes, placement and cost comparisons for effective service alternatives

12. Arizona/Texas LTC Program(s) n State Medicaid Agency Retains Responsibility For: l Determining Member Program Eligibility (Both Financial and Medical) l Health Plan Assignment l HCFA Waiver/State Regulations l Program Compliance Monitoring/Auditing l RFP Development, Scoring and Awards

13. Ventana Health Systems A Wholly Owned Subsidiary of Lifemark Corporation n Arizona Health Care Cost Containment Systems’ Long Term Care System (ALTCS) program contractor since January 1989 n Serving the most chronically ill of the Aged, Blind and Disabled at- risk for nursing home placement n Providing services in 9 rural counties of Arizona n Pre-paid, capitated health plan for 1,900+ LTC members n A fully integrated services approach coordinating institutional, home and community based services, behavioral health, pharmacy and medical care services n Member satisfaction indicates improved functionality and quality of life Arizona

14. Percentage of Lifemark/Ventana Health Plan Members in Institutional vs. HCBS Settings Source: Ventana Health Systems Claims and utilization data. Impact on Member Placement Movement Toward Home and Community Based Services

15. Ventana Health Systems A Wholly Owned Subsidiary of Lifemark Corporation Caseload limits are (case manager-to-member ratios): n 1/48 HCBS, acute care/hospice members (visits every 90 days) n 1/120 nursing facility members (visits every 180 days) n One case manager for mixed caseload of approximately 96 clients (nursing facility and HCBS) n Ventilator dependent members case managed based on setting Subset of Clinical quality outcomes are monitored by measuring: n Influenza n Sacral/Coccygeal pressure ulcers n Hospitalization and emergency room utilization n Activities of Daily Living n Fractures related to falls Arizona

16. n Pilot demonstration started in Harris County (Houston), Texas January 1998 n Integrates acute medical, LTC, behavioral and community based services into a managed care delivery system n Emphasis on least restrictive setting and intensive care coordination n Three health plans awarded contracts, covering over 52,000 members n Primarily mandatory enrollment n Lifemark manages over 19,700 LTC (NF and CBA) and SSI (ABD) recipients - the largest in the STAR+PLUS program HMO BLUE/STAR+PLUS 100% Administered Managed by Lifemark Corporation Texas

17. HMO BLUE/STAR+PLUS Managed by Lifemark Corporation Caseload limits are determined by need (case manager/member ratios): n Level I - 1/2,500 members n Level II - 1/250 members n Level III - 1/100 members n Level IV - 1/30-60 members Current clinical quality outcome studies are: n Depression n Childhood asthma n Adult diabetes n Breast cancer screening Texas