Care Coordination Model:Meeting the Needs of the I/DD

Population

October 30, 2014

Population Served

Background & Challenges

Model of Care

Strategic Priorities

AGENDA2

POPULATION SERVED Average age – 52 years old

62% with mild/moderate Intellectual Disability (ID) diagnosis; 38% with severe/profound ID

34% with communication challenges; 23% with ambulation/mobility challenges

43% are 50 – 64 years old; 18% are 65 years or older

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POPULATION SERVED 100% of people have I/DD

diagnosis. In addition:

− 52% of this group is considered overweight (BMI > 25)

− 41% of this group has secondary MI diagnosis

− 26% of this group has heart disease

− 3% of this group has asthma

− 1% of this group has substance abuse issues

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ENVIRONMENTAL CHALLENGES Few physicians willing to take on

Medicaid patients with ID diagnosis.

Willing providers scattered across wide geographic location, making travel time a significant challenge.

Reliable, long term patient/doctor relationships almost impossible.

Quality of care and follow-up inconsistent at best.

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MEDICAID WAIVER

Medicaid Waiver offers minimal support for integrated, coordinated care approach− Partially funds nursing professional− Funds intervention, individual and

group counseling behavioral services− Does not fund transportation, in-

appointment staff support, specialized medical case management, capital costs associated with clinic operations

Residential service providers are required to coordinate care – effort is currently fragmented and inefficient

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OUR RESPONSE

Create clinic-based medical homes co-located at existing day service sites

Specifically designed to meet needs of people with ID diagnosis− Reduces missed appointments− Improves follow-through with

treatments, care and transitions− Facilitates access to specialty services− Reduces reliance on expensive skilled

care − Maximizes cost savings AND improves

outcomes

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MODEL OVERVIEW: CLINIC SERVICES Medical homes/clinics dedicated to ID

population – 3 clinics currently in operation

Clinic staffing consists of:− Medical Services Coordinator –

Provides medical case management, 24 hour on-call support

− Nursing professionals – 24 hour on-call support

− Team of behavioral services professionals

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MODEL OVERVIEW: CLINIC SERVICESClinic services include intensive medical case management:

Arranging services with providers Coordinating transportation and

support Fully-supported health care visits Keeping track of all client

appointments Scheduling follow-up appointments Monitoring/coordinating following

through on client treatments and medications

Supporting transitions

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MODEL OVERVIEW: COMMUNITY PROVIDER NETWORK Operating agreements with wide

variety of health care providers - providers are independent contractors billing for their own services

Access to an array of services provided on-site and off-site, including:− Primary care− Behavioral and Psychiatry services− Dietary− Gynecology− Neurology− Physical and Occupational therapy− Labs/Testing/Pharmacy− Dental Care

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MODEL OVERVIEW: CARE DELIVERY PROFILE 7,142 medical encounters coordinated

in FY 14 (as of 6/30/14) percent of E.R. encounters = less than

1.9% of total (135 total E.R. encounters) 13,332 behavioral services provided in

FY 14 Care delivered on-site at clinics: 87%;

Care delivered offsite: 13% Average duration of medical

appointments: Offsite – 2 hours, 10 minutes Onsite – 15 minutes

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MODEL OVERVIEW: CARE DELIVERY PROFILEKey elements:

All individuals are linked to a primary care physician, care coordinator and pharmacy provider on day one

Care coordination services include 24 hour on call support for medical and behavioral concerns

Services include the training of support staff and family members on the medications and treatments individuals receive

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OUTCOMESOutcome: Individuals receive the care they’ve been scheduled to receive, without unnecessary delays. Performance Indicator: The percent of medical services delivered as scheduled is 99% or greater. Result:

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Fiscal Year

Med Services Scheduled

Med Services Delivered

Total Missed Appointments

Percent delivered on time

2010 7,999 7,967 32 99.5%

2011 7,543 7,498 45 99.4%

2012 7,520 7,493 27 99.6%

2013 7,535 7,523 12 99.8%

2014 7,142 7,122 20 99.7%

OUTCOMES14

Outcome: Individuals receive routine, preventative care through their primary care provider, rather than through the ER. Performance Indicator: The percent of care provided through the ER is 2% or less of total services delivered. Result: Year

Total Services Delivered

Total ER Encounters

Percent of ER Encounters

2010 7,967 120 1.5%

2011 7,498 137 1.8%

2012 7,520 139 1.5%

2013 7,535 183 2.4%

2014 7,142 135 1.9%

Service intensity declined from FY 2008 to FY 2014 due to effective coordination.

OUTCOMES15

STRATEGIC PRIORITIES Maintain alignment between service

providers and health homes

Preserve co-located clinical model for those we currently serve

Create new clinical capacity to serve 9,000 individuals with ID/DD in North Cook & Lake counties

Support capacity expansion through Keystone IT & Management platform

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Care Coordination Model:Meeting the Needs of the I/DD

Population

Q & A