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What Can We Learn by Performing a Broader Health Risk Assessments?
SPEAKER: RANDALL KLEIN, PRESIDENT
COMPLEXCARE SOLUTIONS, INC
AUGUST 25, 2014
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CCS Today
National company specializing in face-to-face assessment and care management services for Medicare Advantage (MA), MA Special Needs Plans (SNP), Medicaid – Medicare Plans (e.g. MMP, MLTC, Dual Demonstration), Health Insurance Exchange (HIX) and Commercial members
Care management and assessment services approached from comprehensive health perspective, oriented towards integrated pillars of clinical, social and financial responsibility
Management team with deep plan-side knowledge and with experience in MLTC, duals and behavioral health populations
Integrated solutions that complement and enhance existing resources:
- Assessment Services: > 120,000/year- Prospective: >100,000
- MLTC/Dual Eligible: >20,000
- Care Management: > Average daily census ~6,000
- Quality & Compliance: Increases in STARS/HEDIS
Operational
Under Development
Nashville
New York
San Juan
Richmond
Rochester
Albany
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Dual Eligibles: Overview
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Dual Eligibles
Who are Dual Eligibles? 9 million beneficiaries are “dual eligible”- constitute one of the nation’s most vulnerable and costly
populations Account for 15% of Medicaid enrollees but 40% of Medicaid cost 2/3 of Dual Eligibles are older than 65 and roughly 1/3 are younger than 65 with disabilities 55% have annual incomes below $10,000 Half are in fair or poor health, more than twice the rate of other on Medicare enrollees More likely to have mental health needs and to live in nursing homes
Eligibility Standards Enrolled/Eligible for both Medicare and Medicaid programs Must navigate both Medicare and Medicaid to access services, use Medicaid to pay Medicare
premiums and to cover critical benefits Medicare does not cover (long term care)
Kaiser Family Foundation. Dual Eligibles: Medicaid’s Role for Low-income Medicare Beneficiaries. April 2012.
Cms.gov- Medicare-Medicaid Coordination. July 2014.
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Duals Require Substantial Acute and Long Term Care
KFF Medicare’s Role for Dual Eligible Beneficiaries.
Inpatient Hospital, 27%
Medicare Advantage,
18%Providers,
16%
Drug Subsidies,
15%
Outpatient, 10%
SNF, 6%
Home Health, 5%
Hospice, 3%
Distribution of Medicare Spending for Dual Eligibles, By Service
Long Term Care, 69%
(Nursing Facility 41.1% of LTC; ICF-ID 11.1%;
Home Health and Personal Care 45%; Mental Health 2.8%)
Medicare Premiums, 9%
Medicare Acute Care Cost …
Acute Care Not Covered by
Medicare, 56%
Prescription Drugs, 1%
Distribution of Medicaid Spending For Dual Eligibles, By Service
Medicare Spending: $132B Medicaid Spending: $129B
Spending is related
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Several reasons as to why individuals with behavioral health disorders have trouble following the recommended follow-up services for their medical condition:• Lack trust in professionals and agencies• Find the task of seeking medical care overwhelming or frightening• Chronic mental illness individuals can be poor “historians” of their own health and unable to
provide information that medical professionals ned to diagnose their medical problems
These obstacles exacerbated with poverty and other disadvantages found in the Dual Eligible populations• Roughly 40% of the Dual Eligible population has a mental health disorder
Behavioral Health: LTC Execution difficulties
Overview: Health Risk Assessments
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Information Captured: Health Risk Assessments
Health Risk Assessments (HRAs) are standardized assessments that facilitate comprehensive identification and diagnosis of health conditions to highlight individual risk factors and provide feedback
• Basic objectives are to assess the health status, obtain level of health risk, and offer insight to motivate individual change to health risk before claims incur
Payers proactively target high-risk members with high likelihood having incomplete health risk “coding” to complete an HRA
Gather information pertaining to:• Demographic characteristics• Lifestyle• Personal the family medical history• Physiological data• One’s willingness & level of motivation to change health
Overall HRA score acquired upon completion of individual questions or combinations of questions • Score may triggers series of intervention suggestions for review
Bain & Company. December 2012.
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Health Risk Assessments: Delivery Methods
Internet – useful in commercial & HIX populations, but not in duals or MLTC
Telephonically as part of the prescreening or stratification method
HRAs can be completed by providers during annual wellness visits, however, not all providers do this
• Of those, less than 50% receive a full HRA
In Home Assessments: Accurate and thorough documentation with the development of member centric care plan
.
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Types of Assessments for Duals
Medicare Risk Assessments Annual Wellness Visit (AWV) Prospective Other
Functional Assessments
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Attributes of Medicare Risk Assessments
Home or Clinic
Skilled Nursing Facility (SNF)
Selection Algorithm to Maximize ROI X X
Use of Credentialed NP, PA & MD Staff X X
Turnkey Program Admin (e.g. call center, member communication, etc.)
X X
Electronic Data Capture: Data Exchange X X
Automatic Care Plan Generation X X
Palliative & Hospice Assessment X X
Gap Closure via Follow-Up Program Capabilities X X
Use of Facility Medical Record to Inform Assessment X
SNF Specific Care Plan Recommendation X
Ability to Link to SNF-Specific Model of Care X
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Attributes of Functional Assessments
Functional Assessment analyzes individuals ability to perform and manage tasks that are crucial for daily life in order to gain insight into behavior or function
Items evaluated: Activities of Daily Living (ADLs): basic self care such as bathing, dressing, grooming, toileting,
transfers, ambulation, feeding, and medication adherence Instrumental Activities of Daily Living (IADLs): mentally more complex skills such as: meal
preparation, shopping, housework, and laundry.
The evaluation will steer physicians and professionals in appropriate direction for care management and intervention by: Prioritizing which diagnosis to place most focus on Diagnose and assess the stage of a cognitive diagnosis Identifying the level or type of service (personal care or skilled nursing) required to keep an
individual at home on a day to day basis.
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Value of Broader Face to Face Assessment
Loved ones stay safe at home due to a higher quality of living
Face to Face
Use of Credentialed NP, PA & MD Staff
Electronic Data Capture: Data Exchange
Automatic Care Plan Generation
Palliative & Hospice Assessment
Gap Closure via Follow-Up Program
Use of Prior claim data to Inform Assessment
Update Care Plan Recommendation to Health Plan and PCP
Ability to Link to Health Plan Model of Care
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Assessment Processes Can Be Linked
Gaps
Address care plan
interventions
VISITInterventions added to care
plan
Disqualify for CMSelf Care or Health
Plan Education
NotImpactable or Required
Care Plan Generated
MLTC & NP Visit
Care Management Visit
Stars?
Yes
NoImpactableor Required
Candidate
Disenroll back to plan CM when all Care Plan
interventions Closed
High Touch CM
Health Plan CM/DM
Short Term CM
Transition of Care
Impactable with Face to Face & Follow-up
NP Physical Assessment
Star assmt (client
specific)
MLTC Assessment
Health PlanMember
PCP
Mail to
CCS Care Management Assessment
Plan Type
no
yes
HRAs and Risk Stratification
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Member Input &
Selection
Member Outreach
Identify Levels of
Risk
Risk Stratification
• Telephonic Health Risk Assessment conducted by NP or physician
• Identify gaps in care and overall improvement score (score delta)
• Analysis to prioritize which members are most in need of ongoing care (highest score delta)
• Based on combination: Telephonic HRA, face-to-face in-home assessment, and claims
• Identify top priority candidates for intervention
• Utilize professional, facility, pharmacy claims, market, population demographics, recent hospitalization
• Heavily analytical approach
Wellness orientedLow
Telephonic HRA Completion Outreach Technology driven care planning
On-going telephonic interventionMedium
In-home visit -full assessment for on-going care management engagement based on scenario
High
Stra
tifi
cati
on
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Risk Description High Risk Criteria
High Risk
Member who is unsafe alone, cannot be without assistance for even a short period of time, has compromised medical and behavioral health needs.
3 or more hospitalizations, trips to emergency room, falls, and medication changes in last 3 months Bed bound- requires turning and repositioning Uncontrolled Diabetes and Asthma, COPD, Heart Failure (III or IV), Advanced cognitive disorder, 4 or more
chronic conditions Recent Behavioral health crisis: danger to self/others in last 3 months Consistently non-adherent to medication/treatment plans
Moderate Risk
A member with some or all of the
following may qualify as moderate risk.
These members have a caregiver living in
the home and/or willing to help.
6-12 hours of personal care services
Less than 3 hospitalizations within last 3 months
Less than 3 trips to Emergency Room within last 3 months
Less than 3 falls within last 3 months
May have moderate cognitive impairment
Has history of Serious Mental Illness; currently stable and adherent with behavioral health medications
Adherent with medication regimen, requires prompting to self-administer medications
Low Risk
A member who needs help with some
ADL’s but is safe home alone and once
their ADL needs are met.
Criteria includes
Less than 6 hrs/day of personal care service
Compliant with medications and medical appointments.
May have mild cognitive impairment
May use walker to support mobility
No history of serious mental illness or current psychotropic behavioral health medications
Long Term Care Risk Criteria
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Risk DescriptionFrequency of Face to
Face Intervention
Frequency of
Intervention either face
to face or telephonic
High Risk
Requires weekly monitoring of Participant’s
status and/or at least bi-weekly communication
with Participant’s medical and other service
providers
Monthly Weekly
Moderate
Risk
Requires q 3-4 week monitoring of Participant’s
status and/or at least monthly communications
with Participant’s medical and other service
providers
Quarterly Once a month
Low Risk Requires monthly monitoring of Participant’s
status and/or at least quarterly communications
with Participant’s medical and their service
providers
Biannually Every month
Long Term Care Risk Stratification
Post Assessment: LTC Planning
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Fragmentation of LTSS Services
Development of care plan
• Design of care plan in coordination with physicians, social workers, and care givers
Ongoing in-home medical care
• Nursing services to provide in-home clinical services such as wound treatment
Medication management and reconciliation
• Identifying proper medication regiment and ensuring its implementation
Behavioral health services
• High-touch services tailored for members with behavioral or complex health conditions
Activities of daily living (i.e. bathing, hygiene, etc.)
• Home health aids to provide basic living tasks aimed at providing adequate living standards
Provision of regular meals
• Design and delivery of meals to home-bound members, accounting for nutrition concerns
Transportation to and from medical appointments
• Scheduled transportation for members who cannot transport themselves
“Fall-proofing” of residence
• Analysis of home environment to ensure physical safety of members
Social and community services
• Social services such as adult day health care and wellness programs
Identification of highest-risk members
• Analytics to determine members most in need of care management services
Scheduling/ coordination of home care vendors
• Managing the in-home services to be provided to patients, including home health aids
Scheduling coordination of PCP appointments
• Coordinating with providers to ensure timely and appropriate care is provided
Ongoing monitoring of wellness and health
• Regular evaluations and communication to monitor member’s health and wellbeing
Claims processing
• Reporting and filing of claims to ensure proper health reimbursements
IN-HOMEMEDICAL SERVICES
Health risk assessments
• Clinical in-home assessments conducted by licensed nurse
• Used for care plan
IN-HOME NON-MEDICAL SERVICES ADMIN SERVICES
CMS: Outlook on Health Risk Assessments
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Interpretation of the CMS Call Letter
CMS believes the primary purpose of Home Assessment is for risk adjustment.
Despite industry rhetoric, CMS does not believe Home Assessments affect plan liability for care.
After 2 years of warnings, CMS is serious about implementing a change, but has allowed time to study the issue.
CMS believes in the importance of home and community based care.
CMS sees the potential for Home Assessment to be an important Care Management tool and has suggested pathways to promotes its use.
Specific strategies CMS has identified as potential pathways for Home Assessment:
• Conduct as “Annual Wellness Visits”
• Use network providers
• Reach “Homebound” individuals
• Followed by a Provider visit
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CMS and Home Assessments
“In the 2014 Advance Notice, we discussed Medicare Advantage (MA) enrollee risk assessments…We expressed concern that these…could be used as a vehicle for collecting…diagnoses without follow-up care or treatment”
“ In general, treatment is not a component of these risk assessments, although lab…may be performed”
“CMS supports the use of enrollee risk.. for wellness, care coordination, and disease…However, there [is] little evidence…information collected [is used]”
“It is not clear that there is plan liability associated with the provision of treatment for the conditions identified during the assessment”
“We propose for 2015 to exclude for payment purposes diagnoses identified during a home visit that are not confirmed by a subsequent clinical encounter”
Position statement in February 21, 2014 announcement:
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CMS and Home Assessments
• “CMS continues to support the use of enrollee risk assessments for wellness, care coordination and disease prevention; however we remain concerned that many home visits are being used primarily for the gathering of diagnoses for payment rather than to provide treatment and/or follow-up care to beneficiaries.
• …we have decided not to implement the proposal to exclude diagnoses from home visits for 2015 payments. We will study the data submitted by MA organizations to determine appropriate policy options for consideration for 2016 and future years.”
Position statement in April 7, 2014 announcement:
• “Comment:…we received various proposals about the nature of the visit (for example an Annual Wellness Visit) or the provider making a visit (for example a network provider), or the patient being visited (for example, a homebound beneficiary) that commenters were reasonable to allowing to use of the diagnoses collected.
• Response:…we are particularly interested in whether we can identify and measure improvement in care as a result of these home visits and will continue to welcome suggestions for how we can measure such improvement.”
Position statement in April 7, 2014 announcement:
Thank you.
For any questions, please contact:
Randall Klein, President (347) 761-3199
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