1. Jane Mohler, NP-C, MSN, MPH, PhD Professor of Medicine, Public Health, Pharmacy & Nursing Associate Director, Arizona Center on Aging Co-Director, Geriatric Education Center University of Arizona ©AAHCM

2. 9.6 million, 2014

3. ©AAHCM

4. 25% enrollees = 65% costs 6 million 7.5 million

5. ©AAHCM Distribution of Costs Per Dual Eligible by Type of Service, 2007 Service Medicare Medicaid Combined Inpatient Care $7,864 $448 $8,312 Ambulatory Care 2,629 1,299 3,928 Rx Drugs 2,878 83 2,961 Other Acute Care 413 1,613 2,026 SNF/NF 1,139 6,789 7,928 Home Health 928 464 1,392 HCBS and Related Care 0 3,321 3,321 TOTAL 15,850 14,018 29,868 SOURCE: Teresa Coughlin, et al. “The Diversity of Dual Eligible Beneficiaries: An Examination of Services and Spending for People Eligible for Both Medicare and Medicaid.” Kaiser Commission on Medicaid and the Uninsured, April 2012, Table 2, p. 12.

6.  Well targeted interventions for specified subsets  Tailored to individual need  Integrate care  Coordinate care  Improve quality  Decrease high-cost utilization (ed, hospitalization, LTC) ©AAHCM

7. All UA Health Plan Duals (n≈9,000) UA Health Plan Duals in Pima County (n≈4,000) UA Health Plan Duals in Pima County assigned to UAHN primary care provider (n=345) Healthy Together Care Partnership

8. n=345 Population - Cost distribution 15% 5% 30% 50% 48% 37% 14% 1% Within our sub-population, the costliest 5% of enrollees accounted for 48% of total cost of care, while the costliest 20% account for 85% of total cost

9.  Know our population-Stratify by needs  Assume PC of those with advancing chronic conditions, Work closely with PCP if you do not assume PC  Use telehealth and technology only where it makes sense  Measure outcomes  Develop preemptive case management, TOC and social support strategies targeted to individual needs 9

10.  Reduce avoidable ED/ hospitalizations and costs  Maximize med adherence & monitor high cost med outcomes  Accurate HCC scoring to maximize risk adjustment revenue  Improve STARS rating (quality ratings)  Improve pt. experience  Avoid poor TOC and predictable crises 10

11. ◦ Initial health risk assessment (HRA) stratification ◦ Post ED visits and/or hospitalizations ◦ patients identified as high risk to enter into high-cost strata ◦ PCP referrals ◦ Referral from Health Plan 11

12. 12 Team Member (9 total) Role / TasksStaffing FTE* Physician Team LeadProvide overall team clinical leadership0.1 Behavioral Health Director Provide overall team BH leadership0.1 NP LeadManage clinical team1.0 Program CoordinatorManage program0.5 Program ManagerDay to day operations0.5 RN Case ManagerSkilled nursing and case management1.5 Clinical PharmacistPolypharmacy review and medication management (including glow cap adherence and Medicare MM collaboration) 0.2 BH Social WorkerSocial service referral and counseling0.5 Community Health Representative Self-care support1.0 Based on team structure developed for VA Home Based Primary Care program and best available national data

13.  Telehealth  Glow caps (medication adherence monitoring)  Barriers 13

14. Financial summary 14 DRAFT Medical cost reduction of ~20% in the high cost group (n=45) alone is sufficient to achieve net medical cost savings of ~2% across the entire sub- population (n=345)

15.  Telephone and in-person contact,  Coordinators acted as coordination and communications hubs  Relationships  Patient education motivational interviewing or readiness-to-change models to assist patients in overcoming barriers to better adherence to medication and self-care regimens  Medication management  Transitional care interventions-discharge planning and post DC contacts Brown, et al. (2012) ©AAHCM

16.  Population health management through data mining, risk stratification and disease registries  For SNP (pmpm) plans, accurate HCC scoring is vital (non-sustainable)  In-home for Primary Care for Advancing Chronic Conditions  Behavioral Health integration- ANXIETY!!!  Close gaps in care transitions (post ED and hosp)  Community Health Reps for pt education and support  Telehealth may be premature ©AAHCM