1. Developing Service Packages for Integrated Care February 20, 2014 11:30 am – 12:30 pm EST www.mltssnetwork.org

2. Developing Service Packages Offering Choices for Independent Lives Lynn Kellogg, CEO Region IV Area Agency on Aging, MI

3. Aging Network’s Evolution to Medical Partnerships Simultaneous development on 2 levels… Level 1: Product development with Health Plans/Funders Integrated Care [IC] – product design associated with Michigan’s Integrated Care demonstration for persons with dual eligibility [Medicare & Medicaid] Level 2: Product development w/ local hospitals, FQHCs, PCP groups Interagency Care Teams [ICT]: product design associated with avoiding hospitalization readmissions, ACOs, PCMHs and other best practices.

4. Service Packages… Integrated Care [IC] – Level 1 Process: “Unbundling” Medicaid waiver, OAA and state initiatives and repackaging to conform to the Patient Benefit Plan [PBP] required of all health plans competing for a role in the proposed IC demonstration. Includes re-pricing, re-bundling, determination of ability to assume risk and scalability Service examples: supports coordination, transition, assessment, vendor management, housing assistance, self-directed care, all HCBS, evidence- based training Interagency Care Team [ICT] - Level 2 Process: Working w/ case management staff and PCPs from different entities serving the same individuals to achieve better outcomes Service: Creation of ICT to link medical & HCBS providers; capability to shift lead across agencies; HIPAA communication tool

5. Networks… Integrated Care [IC] – Level 1 Who: Other AAAs serving IC demonstration region Service Providers Why:Need to present “single” package to health plan Need vehicles for increased capacity Interagency Care Team [ICT] - Level 2 Who: AAA, FQHC, Hospital, Health Dept. Designed to expand to other entities on Community Roadmap Why:AAA – transitions coaching; linkage to HCBS; ongoing CM FQHC – PCP; care coordination Hospital – Identification of all initial patients; coordination w/ hospitalists, other physician groups Health Dept. – outcome analysis; data tracking

6. Tween Value Expectations… Integrated Care [IC] – Level 1 Cost-effective service network for HP Person-centered approach for consumers Structural partnership between aging network and medical systems Expanded development of HCBS system Expansion of consumer training/empowerment Interagency Care Team [ICT] - Level 2 Reduced hospitalizations Better health outcomes for targeted high risk patients/consumers Less duplication & fragmentation of effort Development of “bundled” payment model for scalability Recognition of merit of AAA product as valued for ACO, PCMH development

7. Tween Results/Commitments… Integrated Care [IC] – Level 1 Scalable service delivery Assumption of risk [under discussion] Commitment to refining system as needed; development of new AAA direct services Creation of legal partnerships w/ otherAAAs for efficient geographic response Interagency Care Team [ICT] - Level 2 Reduction of ED use & hospitalizations; cost reductions Better health outcomes for some diagnoses Consumer empowerment - patient survey Creation of replicable model Initial redirection of staff time making ICT a priority

8. Tween Advice/lessons learned… Integrated Care [IC] – Level 1 Must let go of pre-established terminology and processes Shift to a “business only” model Need to improve/scale up data tracking and analysis Must combine new pricing strategies with volume expectations for negotiations & sustainability Interagency Care Team [ICT] - Level 2 Need to build on relationships Approach from consumer perspective; recognize where work/goals intersect Use reality that major systems have great services but operate in functional isolation, often seeing the same person Creating a Community Roadmap of the range of services available to and used by consumers helped give perspective

9. Questions?

11. Developing Service Packages that appeal to healthcare entities of various sizes, shapes and motivations June Simmons, CEO Partners in Care Foundation Presented to N4A, February 20 th, 2014

12. Partners in Care Who We Are Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care We address social and environmental determinants of health to broaden the impact of medicine We have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhanced patient self-management Changing the shape of health care through new community partnerships and innovations Partners in Care Who We Are

14. 5% spend 50% 1% spend 21% The Upstream Approach: What would happen if we were to spend more addressing social & environmental causes of poor health?

15. 2011 RWJF survey of 1,000 primary care physicians – 85%: Social needs directly contribute to poor health – 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care – 1 in 7 prescriptions would be for social needs – Psychosocial issues treated as physical concerns This is the gap we fill…our value to patients and the healthcare system Healthcare’s Blind Side

16. Why should CBOs be part of the healthcare system? To thrive, CBOs need to play a new role connecting the home with the healthcare system – Home provides unique perspective otherwise unavailable to healthcare providers. – Quality measures for health plans and providers relate to issues such as medication use and fall prevention – HEDIS, Medicare Advantage Star Ratings – Meds are major factor in readmissions (72%) – New focus on population health – identifying and proactively addressing health for high-risk patients

17. Healthcare + HCBS = Better Health, Lower Costs We address social determinants of health – Personal choices in everyday life – Isolation, Family structure/issues, caregiver needs – Environment – home safety, neighborhood – Economics – affordability, access Lower cost structure, high impact, evidence based We help identify where interventions will have greatest impact: – Population health management – prevention – Managing progression of chronic conditions & function – Medication management – Reducing admissions/readmissions & SNF – Late life care – palliative/hospice

18. Targeted Patient Population Management with Increasing Disease/Disability

19. HCBS in Active Population Management – Value Propositions: Who Pays and Who Saves? EOL LTSS & Caregiver Support Care Transitions HomeMeds/Home Safety Assessment EB Self-Management: CDSMP/DSMP; MOB; Healthy IDEAS; EnhanceFitness; PEARLS; Fit & Strong Senior Center – meals, classes, exercise, socialization ED/Hosp: Capitated Providers/Plans Readmission penalties: Hospitals Chronic Disease Management: Duals Plans; MA SNP Prevention: MA Plans; Capitated Med Groups 25% of all Medicare is Last Year of Life: Duals Plans; Medicare Advantage SNP; ACO/MSSP Nursing Home Diversion for Duals Plans

23. Contact Us June Simmons, CEO Partners in Care Foundation 732 Mott St., Suite 150, San Fernando, CA 91340 Main #: 818.837.3775 jsimmons@picf.org www.picf.org www.HomeMeds.org

24. Questions?