Managing Care in Wisconsin

Donna McDowell, MSS, Director

Bureau of Aging & Disability Resources

Division of Long-Term Care

Dept. of Health Services

NASHP October 4, 2011

D. McDowell - Wisconsin 2

Publicly-Funded Long-Term Care Clients by Setting

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

Institution 30,171 30,827 30,270 29,491 28,468 28,395 27,728 26,709 25,630 25,202 24,152 23,137 22,243 20,774 20,297

Pct of Pop 61% 59% 56% 54% 51% 51% 48% 47% 44% 43% 41% 39% 37% 34% 34%

Community 18,907 21,225 23,500 25,574 27,005 27,829 30,184 30,238 32,320 33,615 34,229 35,442 37,680 39,445 39,760

Pct of Pop 39% 41% 44% 46% 49% 49% 52% 53% 56% 57% 59% 61% 63% 66% 66%

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

34%

66%

39%

61%

D. McDowell - Wisconsin 3

How Does Change Happen?

• People want something better

• Choice matters

• Access to an array of opportunities

• Quality is very personal

• Cost-effectiveness is essential

• Combine available resources

• Create good business models

D. McDowell - Wisconsin 4

Look Familiar?

END WAITING LISTS

“There’s No Place Like Home!”

D. McDowell - Wisconsin 6

Medicaid LTC Funding

• Waivers – residential, vocational

• Nursing Home

• Home health, DME, DMS, therapies

• State-only Community Options

D. McDowell - Wisconsin 7

Coordinate v. Integrate

• Hospital

• Physician

• Acute

• Primary

• Rx

• Hospice

D. McDowell - Wisconsin 8

Medicaid Managed Care Program for SSI and SSI Related Recipients

• 2003-05 Biennial Budget required certain SSI recipients to enroll in MA managed care

• Individuals dually eligible for both Medicare and Medicaid may enroll voluntarily.

• All eligible individuals, aged 19 and older who are SSI MA not currently enrolled in a managed care program (Family Care, PACE, or Partnership), are enrolled. Choice, after an initial two month mandatory trial period, to opt out of the program.

• Fifth month enrollees are locked into the managed care plan for an additional eight months.

D. McDowell - Wisconsin 9

Aging & Disability Resource Centers

• One-stop shopping for information and advice about issues of age, disability and long-term care.

• Easy access to knowledgeable professionals about programs, housing and eligibility.

• Counseling about array of options for private pay and indigent clients

D. McDowell - Wisconsin 10

Objective and Prompt Service

• Uniform questionnaire screens individuals to determine what difficulties person has functioning (functional screen).

• Web-based functional screen automatically determines eligibility for public programs: Family Care, Partnership, IRIS

• Easy access to prompt financial eligibility determination

D. McDowell - Wisconsin 11

Combining Services Under One Umbrella

• Elderly benefit specialist

• New disability benefit specialist

• Prevention of disability, e.g. elderly falls prevention

• Transitions for children with disabilities to adult programs

• Information and assistance for persons with mental health concerns

D. McDowell - Wisconsin 12

Enrollment Counseling

• Mandatory for managed care

• Organizationally independent of MCO

• Public entity

• Functional eligibility (home visits)

• Explain program elements

• Support decision-making

• Enroll individual in program of their choice

D. McDowell - Wisconsin 13

Expansion

• Current 35 ADRCs for 55 counties• Serve 85% of population• Statewide expansion by 2013• $50 million AF; claim MA thru time

reporting• 350,000 contacts/year• Tribal Aging & Disability Specialist• Milwaukee ARC & DRC

D. McDowell - Wisconsin 14

OPTION: Family Care

• Elderly, physically or intellectually disabled

• Over 40% have mental health problems

• Integrated, person-centered LTC

• Social Worker/Nurse Care Team

• Comprehensive Assessment

• Care Plan identifies personal goals

• 8 MCOs:non-profit, county,public authority

• Provider network to met all needs

D. McDowell - Wisconsin 15

Family Care Costs

• 31,256 members in 2010; av. $2900 pmpm• $976 million Family Care: adaptive ,DME,day,

care mgt, home care, home health, therapies, housing, residential (no room/ board), respite, transport, vocational, nursing home

• $94.8 million Medicaid: acute, primary, hospital, doctor, Rx fee-for-service not in cap rate

• Approaches to incentivize care at home are key to cost-effectiveness & sustainability

D. McDowell - Wisconsin 16

OPTION: Partnership

• Integrates Long-Term and Primary Care

• Integrates Medicare and Medicaid

• Nurse Practitioner & Social Worker team

• Special needs plan

• 3 non-profit MCOs in 8 counties (incl. Milwaukee) also provide Family Care

• For-profit (also SSI managed care)

• One PACE: two sites

D. McDowell - Wisconsin 17

Self-Direction

• IRIS – Include Respect, I Self-direct

waiver services

• 3393 IRIS participants

• Family Care has 3,000 members self-directing services of their choice

• IRIS waiver does not include MA ffs; participants can self-direct MA personal care

D. McDowell - Wisconsin 18

Information on Website

• Family Care http://dhs.wisconsin.gov/ltcare/• Family Care Partnership

http://dhs.wisconsin.gov/wipartnership/• ADRC http://dhs.wisconsin.gov/ltcare/adrc• Family Care Expansion

http://dhs.wisconsin.gov/managedltc/• Medicaid SSI HMO Choice Booklet

http://www.dhs.wisconsin.gov/publications/p1/p12770a.pdf• ForwardHealth Enrollment and Benefits handbook

http://www.dhs.wisconsin.gov/em/impubs/pubs/p-00079.pdf