Building an Integrated Care Team: ICOs & ASAPs

November 19, 2012

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Mass Home CareThe COMMUNITY LIVING Program

Topics

ASAP Network Readiness to Contract with ICOs – Joan Butler, Executive Director, Minuteman Senior Services

Community Care Linkages – Amy MacNulty, Project Director

The COMMUNITY LIVING Program – Amy MacNulty

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MA ASAPs Ready to Meet ICO LTSS Coordination Requirements

and more…Participation on interdisciplinary primary

care teamRN assessments (CDS) and comprehensive

functional assessmentAvailability to consumers in their home

and across settingsCredentialed and experienced workforce

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As member of ICT, ASAP LTSS Coordinators will be responsible for:

(Sec. 4.6D 2. Care Delivery Model)

Represent the LTSS needs of the Enrollee (a.)

Advocate for the Enrollee (a.) Provide education on LTSS to the

ICT and the Enrollee (a.) Provide LTSS coordination,

including assessments (a.) Evaluate the Enrollee’s Individual

Care Plan and monitor the plan at the Enrollee’s direction (a.)

Participate in initial and ongoing assessments of the health and Functional Status of Enrollees (b.)

Develop the community-based component of an ICP (b.)

Arranging and, with the agreement of the ICT, coordinate the authorization and the provision of appropriate community LTSS and resources (c.)

Assist Enrollees to access PCA Services (d.)

Monitor the appropriate provision and functional outcomes of community LTSS (e.)

Determine community-based alternatives to long-term care (f.)

Assess appropriateness for facility-based LTSS, if indicated (g.)

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If Enrollee has LTSS needs, ASAP LTSS Coordinators will participate

as a full member of the ICT:(Sec. 4.6D 3. & 4. Care Delivery Model)

At any time at the request of the Enrollee with LTSS needs (3.a.) During the initial assessment (3.b.) When the need for community-based LTSS is identified by the Enrollee

or ICT (3.c.) If the Enrollee is receiving targeted case management or rehabilitation

services purchased by DMH (3.d.) In the event of a contemplated admission to a nursing facility,

psychiatric hospital, or other Institution (3.e.) Assist in identifying a more appropriate LTSS Coordinator, if after initial

assessment, it is determined that the Enrollee has specific needs outside the LTSS Coordinator’s expertise (4.)

ASAP LTSS Coordinators will meet qualifications established by ICO, at a minimum:

(Sec. 4.6D 5. Care Delivery Model)

A Bachelor’s degree in Social Work or Human Services, or at least two years working in a human service field with individuals with disabilities (a.)

Completed training that includes education on person-centered planning and person-centered direction (b.) and the independent living philosophy

Experience and expertise in working with people with disabilities and/or elders in need of independent living supports and LTSS (c.)

Knowledge of the home and community-based service system and how to access and arrange for services (d.)

Experience in conducting needs assessments for LTSS needs and with monitoring LTSS delivery (e.)

Cultural Competence and the ability to provide informed advocacy (f.)

Ability to write an Individualized Care Plan and communicate effectively, verbally and in writing, across complicated service and support systems (g.)

Met all requirements of their ASAP employer (h.)

ASAP network has been time-tested, and proven to be deserving of the public trust for the responsibility of operating the Commonwealth’s Home Care Program.

As delegated agents of the Executive Office of Elder Affairs, the ASAPs collectively offer a common suite of Home and Community Based Programs and Services from border to border.

Programs are operated with statewide standards and procedures to ensure consistent quality.

However the governance design also allows for the necessary degree of local customization which is inherent and necessary with the delivery of home and community based services.

MA Executive Office of Elder Affairs

“For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives.” – Secretary Kathleen Sebelius

MA ASAPs History & Mission

Established in 1974 by state law to create community alternative to nursing home care for low income MA residents 60+ who needed assistance with ADLs (coordinate services on behalf of Medicaid eligible members 60+, Chapter 19A,4B)

Unique statewide infrastructure for home and community based care with 40 years experience serving people with chronic care needs and their caregivers over the long term

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MA ASAP History & Mission Con’t

Functional orientation to independent living in the community over the long termo In MA – home care (certified) and home care (ADL assistance) o Embrace consumer choice and empowermento Well positioned to assist consumers to integrate healthy lifestyle and

compliance with medical instructions into daily living Largest conduit of state and federal funding for long term

services and supports delivered to local communities Evolved as single entry point to wide range of in home and

community based options and supports for broad population of seniors, disabled adults and caregivers

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Who are the MA ASAPs?

27 Not for Profit organizations who are members of Mass Home Care

Statewide network that covers every city and town Located in communities served Members of community on Board of Directors Specialize in assessment and care coordination &

SNF Diversions and managing a vendor network Standardized assessment tool and client data

system

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ASAPs serve every city & town

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FY11 ASAP Spending ~$340m

On Behalf of MA Executive Office of Elder Affairs

2011 People Served Statewide

55,800 Clinical Assessment & Evaluation

66,200 Home Care/Respite Care, Enhanced Community Options & CM, Community Choices & CM

18,282 Protective Services reports

ASAP Programs & ServicesEvidence Based

ProgramsCare Transitions ( Coleman Model ) Patient Centered Interdisciplinary Addresses continuity of care across

settings and practitioners Uses Personal Health Record Teaches Self Management Healthy Living Programs Chronic Disease Self Management

(Stanford Program)o Diabetes Self Managemento Arthritiso Chronic Pain Management 2013

Mental Health and Depression Matter of Balance Fall Prevention Healthy Eating Power Tools for Caregivers

Home assessments of a person's functional ADL's & IADL'so Cognition, Depression and Nutritional

Screeningo Home Safety Assessment o Advance Directives

Caregiver supports Authorize, purchase and monitor home &

community-based services (extensive vendor network)

Medication management assistance Nursing Home Pre-Admission Screenings Counseling on Community Options Money Management Elder Abuse & Neglect Investigations and

Intervention Referrals to wellness/disease prevention

resources

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Community-Based Supports

Model of Home CareIndependent Care Management Plus

Vendor Network* with 1,400 contracts statewide

Personal Care Assistance Homemaking & Home Chores Laundry & Grocery Shopping Home Health Services-Skilled RN,

OT, PT, Speech Therapy Supportive Home Care Aide Adult Day Health Care Alzheimers Day Programs Habilitation Therapy Safe Return Wander Locator

Meals on Wheels Transportation Personal Emergency Response Medication Dispensing System Adaptive Housing/Assistive

Technology Short term residential respite in

Nursing Facility, Assisted Living In Home Respite Mental Health

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* Vetted and monitored for compliance and quality* Vetted and monitored for compliance and quality

ASAPs offers information and referral for consumer education & access to

local and statewide services

Public benefits, food stamps/fuel assistanceo SHINE

Private Pay services Housing options Transportation Groceries/Pharmacies that

deliver Senior Dining Senior Centers/COAs Support Groups Employment

Nursing Home Ombudsman Assistive Technology Assisted Living Facilities Nursing Facilities Elder Law Attorneys Driving resources Disease specific resources:

Alzheimers, MS, ALS, Parkinsons Fact Sheets/Seminars Life long learning LGBT resources

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ASAP Consumers Served Annually Over 100,000 calls for Information and Referral

69,000 seniors received Care Management & in home and community based services (14,500 were nursing home level of care)

75,000 received Meals on Wheels or community nutrition services

50,000 Nursing home screenings to assess potential for return to the community and transition assistance

24,000 SCO members served by ASAP GSSCs

550+ consumers received Options Counseling services

Serving adults of all ages with disabilities and their caregivers

Since the 1980s, ASAPs have coordinated MassHealth services that serve adults with disabilities.

14 of the ASAPs are Personal Care Management Agencies (PCMs)

10 of the ASAPs manage Adult Foster Care programs

12 of the ASAPs manage Group Adult Foster Care (GAFC)

Founding partners of MA Aging and Disability Collaborations (ADRCs)

ASAP Workforce Capacity & Expertise

Care Coordinators/Care Managers (944) RNs (265) RN Supervisors (39) Total Employees (3,351) ASAP staff are culturally and linguistically diverse to match the

needs of the community (ASAP Case Staff speak 55 languages and translators available in all areas)

Expertise in services for elders and adults with disabilities and chronic conditions

Experience and expertise in person-centered care, consumer engagement and the independent living philosophy

Experience in managing a capitated system for a fee for service network

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ASAPs Alternative to Nursing Homes

Staying Home: (ECOP/Choices)ASAPs manage programs targeted at people who meet the clinical criteria for the nursing home level of care.

10,248 elders per month are not in nursing homes in MA today because of ASAP services

Results: $266 million annual savings

Returning Home: (CSSM)ASAP staff visit nursing homes to screen elders on a pre-admission and post-admission basis

to determine their ability to return home to design a care plan to transition to home to avoid NF placement at the beginning

Money Follows the Person Initiative

Between July 12, 2011 and June 30, 2012, 168 people have been transitioned out of nursing homes. Another 86 people are enrolled in the program but have not yet been placed.

Of those 168 placements, 125 (74.4%) were elders placed by ASAPs.

19 (11.3%) were DD/ID, 22 (13.1%) were physically disabled, and 2 (1.1%) were MH clients.

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SCOs & ASAPs: Template for ICOs

Geriatric Support Service Coordinators are members of the primary care team who:

may assess all enrollees upon enrollment coordinate community support services with the agreement of

primary care team coordinate non-covered services (housing, home-delivered

meals and transportation) monitor outcomes & track enrollee transfer review enrollee care plans

ASAPs currently manage Vendor Network for 3 SCOs : Long term services and supports

2+ years of Collaboration & Partnering in response to Health Reform Initiatives oCCTP/Section 3026oPioneer ACOsoPCMHs/Physician Practiceso Self Management Supports/CDSMPo ICOs

The COMMUNITY LIVING Program22

Community Care Linkages SM

A Division of Mass Home Care

Community Care Linkages is a strategic initiative to effectively integrate services of the Massachusetts Aging Services Access Points (ASAPs) into the evolving healthcare delivery system.

MA ASAPs Involved with multiple Innovation Center

Initiatives

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CMS Payment to MA ASAPs for Care Transition Services at part of CCTP

1. Elder Services of Berkshire County Berkshire Medical Center and

the Berkshire Visiting Nurse Association

2. Elder Services of Worcester & BayPath Elder Services MetroWest Medical Center; St.

Vincent Hospital; UMass Memorial Medical Center; Wing Memorial Hospital; Marlborough Hospital; Clinton Hospital, and HealthAlliance Hospital

3. Somerville-Cambridge Elder Services & Mystic Valley Elder Services Cambridge Health Alliance and

Hallmark Health System

4. Merrimack Valley of Massachusetts and Southern New Hampshire Elder Services Anna Jacques Hospital, Saints

Medical Center, Holy Family Hospital, Lawrence General Hospital, and Merrimack Valley Hospital 24

http://innovation.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html

47 partners announced in three rounds, 4 in Massachusetts

http://www.healthyliving4me.org

The COMMUNITY LIVING Program

The Community Living Program is offered exclusively through Mass Home Care and offers beneficiaries of ICOs, ACOs, PCMCHs, and other care provider organizations access to a wide range of vetted home and community based supports, including care coordination, member education and engagement, and registered nurse assessments.

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Statewide network of ASAPs are aligning with local and national trends towards integrating aging and disability services.

Statewide network of ASAPs are aligning with local and national trends towards integrating aging and disability services.

Member-Centered Long Term Services for Dual Eligibles:Statewide networkSuccessful partnering with community agencies and medical providers

o ILCs, ADRCs, SCOs, ACOs, PCMHs, FQHCs

Key Serviceso Initial Assessmento Basic Coordinationo Complex Care Coordinationo RN Assessmentso Network Managemento Evidenced-Based Healthy Living Programso Care Transitions Coaching

A Mass Home Care Initiative for Integrated Care Organizations

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The COMMUNITY LIVING Program for ICOs*

Putting the pieces together

*Refer to handout for narrative

LTSS Coordinator

Initial Assessmento In-person, comprehensive initial assessment (CDS/MDS-HC)o Assess functional status (ADLs)o Determine formal and informal supports

Care Coordinationo Conduct Comprehensive Person-Centered Assessmento Develop Care Plan o Engage Informal Supportso Assess Risk and Care Team Managemento Coordinate Services Across Care Continuumo Assist with Nutritional Plan of Careo Care Transitions Coaching

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ASAP RN Assessments

Experience with initial and on-going assessments (CDS/MDS-HC)

Conduct assessment and plan of care for personal care (non-PCA)

Complete PCA evaluations

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Network Management

30+ years experience with successful management of vendor networkoEmploy standard statewide protocols for

contracting, monitoring, quality, compliance

Respond to ICO needs to develop/expand services and programs

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Evidence Based Health Living Programs

Chronic Disease Self Management (Stanford Program)oDiabetes Self ManagementoArthritisoChronic Pain Management 2013

Mental Health and Depression Matter of Balance Fall Prevention Healthy Eating Power Tools for Caregivers

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Matrix of ASAP Statewide Capacity*

*Refer to handout for complete matrix

What ASAPs can offer your members:

LTSS Coordinationo Initial Assessment (CDS/MDS-HC)o Basic Coordinationo Complex Care Coordination

RN Assessments Network Management Nursing Home Screening Evidenced-Based Healthy

Living Programs Care Transitions Coaching Caregiver supports

Authorize, purchase and monitor home & community-based services (extensive vendor network)

Medication management assistance Counseling on Community Options Money Management Elder Abuse & Neglect

Investigations and Intervention

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