Health Home Implementation Update

1
Health Home Implementation Update

• Session 6
• October 10, 2012

2
Agenda

• Status of Health Home Implementation
• Payment updates
• Projected Health Home Assignment
• Overview of Datamart Portal
• Role of LGU and BHOs as Health Home partners
• Interim Referral Guidance

3
PHASE 1 SNAPSHOT

• 13 Health Homes designated, HHs, MCPs and
  converting CM programs may bill for Health Home
  services.
• DOH, HH and MCPs developing operational policies
  and procedures and improving the transmission of
  Health Home Patient Tracking file information
  between NYS DOH and Health Homes and MCPs through
  the DOH OHIP Portal.

• Bronx BAHN, HHC,VNS of NY Home Care, Bronx
  Lebanon Hospital Ctr.
• Brooklyn Maimonides, Community Health Care
  Network, ICL, HHC
• Nassau NS-LIJ, FEGS
• Schenectady VNS of Schenectady and Saratoga
• Northern Region Adirondack Health Institute,
  Inc., Glens Falls Hospital

4
PHASE 2 SNAPSHOT

• Monroe Anthony L. Jordan , Huther Doyle
• Erie Alcohol Drug Dependency Services, Inc.,
  Mental Health Services Erie County -SE Corp V,
  Urban Family Practice,
• Hudson Valley Hudson River HealthCare, Inc.,
  Open Door Family Medical Ctr. Inc., Institute
  for Family Health
• Suffolk FEGS,, Inc, NS-LIJ,
• Hudson River HealthCare
• Staten Island Jewish Board of Family
  Childrens Services (JBFCS)
• Queens Community Healthcare Network, HHC,
  NS-LIJ with PSCH, JBFCS
•  Manhattan Heritage Health Housing Inc.,
  Presbyterian, HHC, St. Lukes-Roosevelt Hospital
  Center, VNS of NY, and JBFCS

• 21 Health Homes designated, HHs are in the
  process of submitting updated network partner
  lists, entering into Data Exchange Application
  Agreements (DEAA) with DOH and executing
  contracts with MCPs.
• DOH in discussions with CMS re SPA approval, HH
  services cannot be billed until SPA is approved
  and rates are loaded

5
PHASE 3 SNAPSHOT

• Northern Region Hudson River HealthCare, Inc.,
  St. Marys Healthcare, Samaritan Hospital,
  Adirondack Health Institute, Glens Falls
  Hospital, Visiting Nurse Service of Schenectady
  Saratoga Counties,
• Central Region Thomas R. Mitchell, Onondaga
  Care Management Services, Inc., Upstate Cerebral
  Palsy, Huther Doyle ,North Country Childrens
  Clinic, St. Josephs Hospital Health Center,
  Catholic Charities of Broome County, United
  Health Services Hospitals
• Western Region Mental Health Services Erie
  County-Southeast Corp V, Niagara Falls Memorial
  Medical Center, Chautauqua County Dept. of Mental
  Hygiene

• 17 HH designated, DOH is in the final stages of
  designating Phase 3 HHs (pending for Albany,
  Otsego, Schoharie, Delaware and Chenango
  counties).
• Designated Phase 3 HHs are working on addressing
  any contingencies identified in the review of
  their applications ,entering into DEAAs and MCP
  contracts and formalizing network partnerships.
• DOH in discussions with CMS re SPA approval, HH
  services cannot be billed until SPA is approved
  and rates are loaded .

6
Initial Health Home Acuity Scores(those in place
for payment prior to Oct 1)

• The base patient acuity factors are weighted
  averages based on total claim costs associated
  with CRGs for a Health Home eligible population
  for a given time period.
• Initial Phase 1 base acuity scores were adjusted
  upward for HIV, MHSA and Single SMI illnesses as
  well as severity level.
• These adjusted acuity scores for Phase 1 HH
  eligible individuals have been provided to Phase
  1 Health Homes and Managed Care Plans.

7
Updated Health Home Acuity Scores(for dates of
service after Oct 1)

• In addition to adjusting the acuity scores for
  Severity and MHSA/HIV/Single SMI conditions, new
  weights include additional upward adjustments
  for
• Individuals that are in the Pairs Chronic and
  Triples Chronic populations that also have
  serious mental illness
• A risk based add-on from the predictive model
  (drives dollars to members at higher risk for
  using more inpatient services)
• The new acuity scores are effective October 1,
  2012 and will be made available to health homes
  and plans via the OHIP HCS Portal.

8
Revised Payment Rates and Method

• Effective October 1, 2012, Health Home payments
  will be based on the new acuity scores and will
  be member specific.
• The new acuity scores or member specific
  weights will be loaded to eMedNY within the next
  week .
• If an individual does not have an acuity score at
  the time a claim is submitted, the claim will go
  into pend status for 30 days. A statewide average
  acuity score (from the HH assigned population)
  will be provided to eMedNY so that the claim will
  pay.

9
Health Home Rate Calculation for Claims with
Dates of Service on/after 10-1-12

• Member Specific Payment Calculation
• member specific acuity x applicable HH base
  rate
• Example 8.2564 x 23.27 192.13
• The payment will be automatically calculated when
  the claim is submitted to eMedNY by the claims
  payment system.

10
Payment Comparisons Pairs Chronic and Triple
Chronic Populations
11
(No Transcript)
12
Additional Phase 1 Health Home Assignments

• Additional Phase 1 assignments will include
  Health Home eligible individuals with a
  Composite Score gt 125 and individuals with a
  Predictive Model Risk of gt 30
• Additional assignments anticipated to be
  available late fall of 2012 via the OHIP HCS
  Portal instead of manually.

13
Phase 2 and Phase 3 Health Home Assignments

• Health Home assignment files will be available
  once DEAAs and Portal Functionality is complete.
• Assignments will be available via the OHIP HCS
  Portal
• Each Health Home and Managed Care Plan should
  have at least one HCS contact to download
  assignment files and upload patient tracking
  files. Test files should be sent now.

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Projected Assignments by Phase (based on July
2010/July 2011 HH Eligible Population)
Members that are not in converting TCM slots - members with a Composite Score gt 125 and members with a Predictive Model Risk gt 30 Members that are not in converting TCM slots - members with a Composite Score gt 125 and members with a Predictive Model Risk gt 30 Members that are not in converting TCM slots - members with a Composite Score gt 125 and members with a Predictive Model Risk gt 30 Members that are not in converting TCM slots - members with a Composite Score gt 125 and members with a Predictive Model Risk gt 30
Phase FFS MMC Total
Phase 1 22,781 49,062 71,843
Phase 2 25,790 55,243 81,033
Phase 3 11,639 18,139 29,778
Unmatched 5,404 555 5,959
sub-total 65,614 122,999 188,613
Members in Converting TCM Slots Members in Converting TCM Slots Members in Converting TCM Slots Members in Converting TCM Slots
Phase FFS MMC Total
Phase 1 5,404 7,224 12,628
Phase 2 8,394 7,629 16,023
Phase 3 3,213 2,842 6,055
Unmatched 653 61 714
sub-total 17,664 17,756 35,420
Total 83,278 140,755 224,033
MMC counts are higher as more individuals have moved to MMC. MMC counts are higher as more individuals have moved to MMC. MMC counts are higher as more individuals have moved to MMC. MMC counts are higher as more individuals have moved to MMC.
Members to be matched to Health Home based on loyalty. Members to be matched to Health Home based on loyalty. Members to be matched to Health Home based on loyalty. Members to be matched to Health Home based on loyalty.
Members to be matched to Health Home by Case Management Agency Members to be matched to Health Home by Case Management Agency Members to be matched to Health Home by Case Management Agency Members to be matched to Health Home by Case Management Agency
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Projected Assignments by County Phase 1(may
include a subset of previously assigned Phase 1
members)
Phase 1 Projected Assignments at Full Implementation (Includes Duals) Phase 1 Projected Assignments at Full Implementation (Includes Duals) Phase 1 Projected Assignments at Full Implementation (Includes Duals) Phase 1 Projected Assignments at Full Implementation (Includes Duals) Phase 1 Projected Assignments at Full Implementation (Includes Duals) Phase 1 Projected Assignments at Full Implementation (Includes Duals)
  Members in Non Converting Slots Members in Non Converting Slots Members in Non Converting Slots Members in Converting TCM Slots Grand
COUNTY FFS MMC sub-total Members in Converting TCM Slots Total
CLINTON 581 216 797 146 943
ESSEX 147 95 242 47 289
FRANKLIN 315 29 344 122 466
HAMILTON 8 12 20 0 20
NASSAU 1,864 4,266 6,130 1,475 7,605
NYC - BRONX 8,836 19,689 28,525 5,221 33,746
NYC - BROOKLYN 10,019 23,255 33,274 5,195 38,469
SCHENECTADY 465 1,141 1,606 254 1,860
WARREN 380 110 490 92 582
WASHINGTON 166 249 415 76 491
Total Phase 1 22,781 49,062 71,843 12,628 84,471
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Projected Assignments by County Phase 2
Phase 2 Projected Assignments at Full Implementation (Includes Duals) Phase 2 Projected Assignments at Full Implementation (Includes Duals) Phase 2 Projected Assignments at Full Implementation (Includes Duals) Phase 2 Projected Assignments at Full Implementation (Includes Duals) Phase 2 Projected Assignments at Full Implementation (Includes Duals) Phase 2 Projected Assignments at Full Implementation (Includes Duals)
  Members in Non Converting Slots Members in Non Converting Slots Members in Non Converting Slots Members in Converting TCM Slots Grand
COUNTY FFS MMC sub-total Members in Converting TCM Slots Total
DUTCHESS 580 1,076 1,656 834 2,490
ERIE 1,826 5,873 7,699 1,437 9,136
MONROE 1,596 4,302 5,898 1,445 7,343
NYC - MANHATTAN 7,877 11,024 18,901 3,529 22,430
NYC - QUEENS 6,033 15,138 21,171 2,995 24,166
NYC - STATEN ISLAND 1,230 3,281 4,511 803 5,314
ORANGE 891 1,780 2,671 388 3,059
PUTNAM 103 197 300 65 365
ROCKLAND 464 1,121 1,585 313 1,898
SUFFOLK 2,615 6,055 8,670 2,767 11,437
SULLIVAN 274 616 890 220 1,110
ULSTER 435 974 1,409 125 1,534
WESTCHESTER 1,866 3,806 5,672 1,102 6,774
Total Phase 2 25,790 55,243 81,033 16,023 97,056
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Projected Assignments by County Phase 3
Phase 3 Projected Assignments at Full Implementation (Includes Duals) Phase 3 Projected Assignments at Full Implementation (Includes Duals) Phase 3 Projected Assignments at Full Implementation (Includes Duals) Phase 3 Projected Assignments at Full Implementation (Includes Duals) Phase 3 Projected Assignments at Full Implementation (Includes Duals) Phase 3 Projected Assignments at Full Implementation (Includes Duals)
  Members in Non Converting Slots Members in Non Converting Slots Members in Non Converting Slots Members in Converting TCM Slots Grand
COUNTY FFS MMC sub-total Members in Converting TCM Slots Total
ALBANY 783 1,973 2,756 397 3,153
ALLEGANY 146 192 338 98 436
BROOME 621 1,082 1,703 324 2,027
CATTARAUGUS 201 537 738 209 947
CAYUGA 312 230 542 98 640
CHAUTAUQUA 339 965 1,304 305 1,609
CHEMUNG 409 439 848 121 969
CHENANGO 309 51 360 58 418
COLUMBIA 165 347 512 78 590
CORTLAND 95 264 359 72 431
DELAWARE 256 48 304 33 337
FULTON 166 450 616 76 692
GENESEE 115 269 384 99 483
GREENE 144 370 514 62 576
HERKIMER 162 289 451 71 522
JEFFERSON 656 36 692 126 818
LEWIS 116 21 137 31 168
LIVINGSTON 109 235 344 70 414
MADISON 195 215 410 85 495
MONTGOMERY 134 429 563 90 653
sub-total 5,433 8,442 13,875 2,503 16,378
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Projected Assignments by County Phase 3 (contd)
Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd) Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd) Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd) Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd) Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd) Phase 3 Projected Assignments at Full Implementation (Includes Duals) (Cont'd)
  Members in Non Converting Slots Members in Non Converting Slots Members in Non Converting Slots Members in Converting TCM Slots Grand
COUNTY FFS MMC sub-total Members in Converting TCM Slots Total
NIAGARA 443 1,246 1,689 679 2,368
ONEIDA 625 1,444 2,069 565 2,634
ONONDAGA 1,108 2,436 3,544 695 4,239
ONTARIO 163 340 503 161 664
ORLEANS 95 240 335 54 389
OSWEGO 205 669 874 159 1,033
OTSEGO 132 257 389 56 445
RENSSELAER 383 1,205 1,588 308 1,896
SAINT LAWRENCE 1,004 51 1,055 106 1,161
SARATOGA 294 820 1,114 138 1,252
SCHOHARIE 72 77 149 39 188
SCHUYLER 113 22 135 31 166
SENECA 72 109 181 57 238
STEUBEN 647 90 737 119 856
TIOGA 239 28 267 28 295
TOMPKINS 198 232 430 148 578
WAYNE 200 297 497 112 609
WYOMING 184 25 209 66 275
YATES 29 109 138 31 169
Total Phase 3 11,639 18,139 29,778 6,055 35,833
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OHIP Datamart Portal

• Currently available to Health Homes and Managed
  Care Plans with Health Commerce System Access.
• Current Capabilities
• Tracking file submission
• Recipient look-up
• find out members HH eligibility, Medicaid
  eligibility, HH enrollment, and assigned members
  last 5 claims
• Enrollment record download (data dump)
• Creates a file containing all records that a
  provider has successfully submitted to the portal
• Upcoming Capabilities
• Assignment file download
• Member acuity score file download
• Member claim detail Report

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CRITICAL PARTNERSHIPS LDSS and LGUs

• Local District Social Services offices (LDSS) and
  local government units (LGUs) can be a valuable
  source of information to help outreach to and
  manage care for assigned members and a referral
  source for new members.
• HH can exchange data with an LDSS or LGU by
  completing a DEAA subcontractor packet. The LDSS
  or LGU should determine which staff members need
  to access HH data (in addition to Medicaid staff
  who are automatically permitted access ) These
  staff members should be listed on the DEAA, and
  access to HH member data would be approved only
  for these individuals.

21
CRITICAL PARTNERSHIPS BHOs

• The State has entered into contracts with five
  regional Behavioral Health Organizations (BHOs).
  The BHOs are monitoring FFS Medicaid admissions
  for inpatient psychiatric care and detox and
  reviewing discharge planning.
• HHs can execute a Confidentiality Agreement with
  their regional BHO and arrange to receive alerts
  if a member is admitted for these services. The
  HH and BHO can work together on discharge
  planning and the BHO can also insure the Health
  Home is part of the discharge planning process.

22
HEALTH HOME REFERRALS

• Potential members may be referred for Health Home
  services
• Members do not have to be on DOH lists or be
  approved by DOH in order to be accepted for
  Health Home referral. HHs and MCPs are
  responsible for determining whether the
  individual presumptively meets criteria for
  referral.
• A Health Home and MCP work group is in the
  process of developing rule-in, rule-out
  criteria for referrals. Interim guidance has been
  developed.
• This process will be used to prioritize referrals
  in the initial phases of Health Home
  implementation (to focus initial Health Home
  resources to our neediest members). This process
  will be revisited when Health Homes are more
  fully implemented.
• There are 3 steps to making a Health Home
  referral

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HEALTH HOME REFERRALS-INTERIM GUIDANCE

• STEP 1- ASSESS ELIGIBLITY Must meet eligibility
  for Health Home Services as described in the New
  York State Health Home State Plan Amendment
  (claims data should be used whenever available to
  verify medical and psychiatric diagnoses)
• Two chronic conditions (e.g., mental health
  condition, substance use disorder, asthma,
  diabetes, heart disease, BMI over 25, or other
  chronic conditions, OR
• One qualifying chronic condition (HIV/AIDS) and
  the risk of developing another, OR
• One serious mental illness

24
HEALTH HOME REFERRALS-INTERIM GUIDANCE

• STEP 2-ASSESS APPROPRIATENESS FOR HEALTH HOME
  Has significant behavioral, medical or social
  risk factors which can be modified/ameliorated
  through care management including any of the
  following
• Probable clinical risk for adverse event, e.g.,
  death, disability, inpatient or nursing home
  admission
• Lack of or inadequate social/family/housing
  support
• Lack of or inadequate connectivity with
  healthcare system
• Non-adherence to treatments or medication(s) or
  difficulty managing medications
• Recent release from incarceration or psychiatric
  hospitalization
• Deficits in activities of daily living such as
  dressing, eating, etc
• Learning or cognition issues

25
HEALTH HOME REFERRALS-INTERIM GUIDANCE

• STEP 3 -INITIATE REFERRAL If member meets
  criteria described in Steps 1-2, the referral can
  be made on the basis of this presumptive
  assessment.
• Referrals for FFS members are made to the lead
  HH, referrals for plan members can directly to
  the MCP or to the lead HH to make the MCP
  connection.
• HHs and plans have access to assignment
  information in the HCS portal and should check an
  individuals assignment status prior to making a
  referral.
• If the individual is already assigned to a Health
  Home, that Health Home should be contacted to
  discuss the appropriate course of action.
• (Additional factors which will quantify criteria
  in Step 2 are under development by the clinical
  workgroup-see next slide)

26
HEALTH HOME REFERRALS-INTERIM GUIDANCE

• Developing Step (coming soon) - QUANTIFY
  RISK/ACUITY
• Has a history of poor connectivity to care,
  including but not limited to
• No primary care practitioner (PCP)
• No connection to specialty doctor or other
  practitioner
• Poor compliance (does not keep appointments, etc)
• Inappropriate ED use
• Repeated recent hospitalization for preventable
  conditions either medical or psychiatric
• Recent release from incarceration
• Cannot be effectively treated in an appropriately
  resourced patient centered medical home
• Homelessness

27
HEALTH HOME REFERRALS-INTERIM GUIDANCE

• NOTE
• If a comprehensive assessment subsequently
  reveals that the individual does not meet Health
  Home services criteria, the individual must be
  transitioned to an appropriate level of care,
  such as a Patient Centered Medical Home (PCMH).
• Referral process for converting TCM programs may
  differ, e.g., OMH TCM programs and services must
  be made in consultation with the LGU Single Point
  of Access (SPOA).
• Detailed instructions on how to use the Health
  Home Member Tracking System to make a referral
  can be found in the Health Home Member Tracking
  System specifications document.

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Resources

• Member Tracking System Specifications Document
  http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/docs/2012-06-26_draft_hh
  _patient_tracking_system.pdf
• Document explaining Tracking System version
  updates http//www.health.ny.gov/health_care/medi
  caid/program/medicaid_health_homes/docs/summary_up
  dates_hh_patient_tracking_system.pdf
• April Medicaid Update Special Edition (watch for
  an article in the October Edition)
• Health Home Website http//www.health.ny.gov/heal
  th_care/medicaid/program/update/2012/april12muspec
  .pdf http//www.health.ny.gov/health_care/medicaid
  /program/medicaid_health_homes/
• Member Assignment, Tracking System, Billing and
  Rates section of Health Home website
  http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/rate_information.htm

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Current Outstanding Issues

• Discussion with CMS re SPAs
• Final recommendations re referrals from Plans
  and Health Homes clinical workgroup
• Working towards assigning children and duals to
  Health Homes

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Questions?

Questions can also be submitted to the Health
Home mailbox (hh2011_at_health.state.ny.us) with the
subject line Questions Health Home Webinar 6