Health Home Implementation Update

1
Health Home Implementation Update A Care
Management Partner Perspective

• Session 9 January 17, 2013

2
Agenda

• Working Together
• HIT Requirements and Funding Opportunities
• Sharing Member Information
• Member Eligibility for Health Home Services
• Outreach and Engagement Work
• Health Home Services
• Acuity Scores
• Billing and Rates

3
Working Together-The Role of TCMs in Health Homes

• The States decision to pursue the Health Home
  (HH) model in a transformative way was predicated
  on the successes and lessons learned in OMH
  Targeted Case Management (TCM), HIV COBRA TCM,
  OASAS Managed Addiction Treatment Services
  (MATS), and DOH Chronic Illness Demonstration
  Project (CIDP)
• HH providers integrate and coordinate all
  primary, acute, behavioral health, and community
  support services treating the whole person with
  the goal to improve care and reduce costs.

4
Working Together-The Role of TCMs in Health Homes

• The HH model expands concepts from both
  converting case management programs and Patient
  Centered Medical Home model by building
  additional linkages and enhancing coordination
  and integration of medical and behavioral health
  care to better meet the needs of people with
  multiple chronic illnesses
• In other words, the Health Home takes the Medical
  Home concept across multiple care disciplines and
  into the community for high need Medicaid
  recipients

5
Working Together-The Role of TCMs in Health Homes

• TCMs were developed to provide community-based
  case management to high need Medicaid recipients
  (HIV/Mental Health) often disengaged from
  medical, mental health, and social services
• TCMs have years of experience in outreach and
  engagement of persons difficult to locate and
  keep in care
• unstably housed
• mentally ill
• history of incarceration
• substance using
• with multiple chronic illnesses
• impacted by stigma

6
Working Together-The Role of TCMs in Health Homes

• HHs networks were approved only if they included
  converting case management programs in many
  cases multiple case management programs.
• Lead HHs are expected to be using the value and
  expertise of their entire HH network to achieve
  the goals of the program.

7
Working Together Challenges

• Case management programs operated successfully,
  but programs were not anchored into formal
  comprehensive networks with medical providers.
• Under HH case management agencies are
  transitioning as part of larger networks.
• TCMs are accountable to HH Leads often multiple
  leads with different requirements.
• TCMs work to ensure client outcomes are realized
  provide direct service to locate/engage clients
  and coordinate member care and services.
• TCM input into HH policies can help ensure more
  effective processes.

8
Working Together Challenges

• Fiscal Viability
• Converting programs ability to generate revenue
  to cover agency administrative and infrastructure
  costs are dependant on volume of assignments, and
  amount and timing of payments
• Concern about future cash flow beyond direct
  Medicaid billing
• Concern about survival beyond legacy rates
• Administrative costs must be negotiated with
  multiple HH Leads and MCOs.
• New infrastructure and HIT costs are not built
  into reimbursement impacting lead HHs and
  network partners alike.

9
Working Together Challenges

• Administrative burden
• Tracking enrollee status for multiple HH
• Reporting to multiple MCOs and HH Leads
• Requirements vary - some have added reporting
  elements beyond state requirements
• Maintaining databases/EHRs for multiple HH and
  ensuring staff are trained to use them
• Building capacity
• Hiring, training, supervising staff
• Oversight and quality assurance

10
Working Together-Lead Agencies and Converting
Programs

• HH network partners have a joint responsibility
  to assure HH outcomes are reached. Establish
  systems to ensure
• Clear, regular communication between HH Leads,
  MCOs, and converting care management providers
• Policy input by all parties
• Communication among HH systems in the same
  region, to avoid overlap and encourage
  collaboration (e.g., HUNNY, CNYHHN)

11
Maintaining Strong HH networks

• State expects movement of partners as
  relationships develop.
• HHs must notify DOH about changes to their
  network (changes in name, partners joining or
  leaving, etc). See instructions on the Health
  Home website http//www.health.ny.gov/health_care
  /medicaid/program/medicaid_health_homes/medicaid_e
  nroll_prov-led_hh_rev.htm
• HHs are responsible to assure they maintain an
  ability to meet provider standards and
  qualifications much of which is met through
  comprehensive network partners working together.

12
HIT Requirements

• Lead Health Home (HH) is responsible for assuring
  the HH network meets final HIT standards
• Network care management partners are not required
  to join a RHIO but becoming a RHIO member will
  enhance the quality and quantity of EHR data
  shared
• Lead HHs should be working with network partners
  to assure partners have any necessary HIT
  capability Work with the partners to fill in
  gaps

13
HIT Requirements

• Lead Health Home is responsible for a plan to
  adopt Certified Meaningful Use (MU) Electronic
  Health Records (EHR)
• This HIT Standard applies to all Health Homes and
  is required for Clinical Partners/Provider
  Organizations providing clinical care to Health
  Home patients (including BHOs).
• Care Managers do not necessarily need an EHR, but
  need an interoperable Care Plan application.
• A future webinar will address this as well as
  other HIT related questions.

14
HIT Requirements

• Partners should work with lead HH to understand
  how the HH will share information and meet HIT
  standards
• Please contact Office of Health Information
  Technology Transformation for specific questions
  
• E-mail healthit_at_health.state.ny.us
• Phone [phone]

15
HIT Funding

• NYS recognizes expense of HIT infrastructure on
  Health Homes
• Lead HHs and partner agencies have varying
  degrees of HIT infrastructure
• NYS requested funding for HIT infrastructure
  through the CMS waiver
• Funding would be prioritized for HH partners that
  have not already received funding through other
  initiatives.

16
HIT Funding

• NYS OMH is providing one-time HIT funding to
  assist former TCM providers to develop electronic
  care management system capacity to share
  information with their respective HHs.
• HEAL 22 has funding to support technical
  assistance for Mental Health/Behavioral Health
  providers working with HHs.

17
Sharing Information

• Access to member information is important to the
  entire HH network.
• Currently only HHs and MCPs can access the Health
  Home member tracking file through the Health
  Commerce System (HCS).
• DOH recognizes that network partners would like
  access to the HCS but current system and resource
  issues prevent the ability to give all network
  partners HCS access.

18
Sharing Information

• DOH is looking to build a HH portal which would
  allow broader access and include additional
  features, such the ability to pull claims
  information.
• In the interim, leads are responsible for sharing
  necessary information with the network partners.
• DOH has a proposal to streamline the member
  tracking system process and will specify a
  standardized file layout to make it easier for
  network partners to manage data submission.

19
Sharing Information

• Tracking system calls are held on a regular basis
  for Health Homes and MCPs because they currently
  submit files directly to NYS.
• Network partners submit files through their HHs
  and are encouraged to obtain tracking system
  information from the respective HHs.
• Information is also available at
  http//www.health.ny.gov/health_care/medicaid/prog
  ram/medicaid_health_homes/docs/2012-06-26_draft_hh
  _patient_tracking_system.pdf

20
Sharing Information

• Health Home Restriction Exception (R/E) codes
  will be implemented in mid-2013. These codes will
  allow member look-up through eMedNY and other
  systems.
• This will be especially valuable to check before
  community referrals are made.
• These codes will identify whether a member is
  potentially eligible for HH services and, if a
  member has been assigned, will identify the name
  of the members HH.

21
Sharing Information

• Currently Health Homes and MCPs can only share
  the five most recent encounters of HH members.
• Until the portal is developed, DOH will work with
  HH and MCPs to see what can be done to improve
  the member information provided to network
  partners, for both assignments and referrals.

22
Member Eligibility

• New lists will be based on more up-to-date member
  eligibility information but eligibility can
  change.
• Health Homes should verify member eligibility and
  assist members on maintaining Medicaid
  eligibility.
• Often Medicaid coverage is granted retroactively.
  However, the decision to provide it retroactively
  is up to the county of residence.

23
Member Eligibility

• DOH is developing guidance on leveraging existing
  strategies for assisting clients with spend down.
  
• New strategies are being explored, focused on
  maintaining eligibility for spend down members.
• Health Homes should work closely with their Local
  Government Unit (LGU)
• It will still be necessary to work with members
  on an individual basis to maintain eligibility.

24
Member Assignment

• New lists for Phase 1 and the first set of lists
  for Phase 2 are being finalized and were just
  released.
• Members may also be assigned to HHs by network
  partners through community referrals.
• See Medicaid Update November Special Edition
  http//www.health.ny.gov/health_care/medicaid/prog
  ram/update/2012/nov12sped.pdf
• Community referrals can be transmitted to the
  lead HH through the member tracking system.

25
Member Assignment

• TCMs/MATS make assignments for their members
• For members previously enrolled in TCM, MATS and
  CIDP programs, the member can choose which care
  manager they want as their HH care manager
• For members of a plan that are not contracted
  with the TCMs/MATS HH the lead HH should contact
  the members plan to initiate contract
  discussions
• When a contract cannot be agreed upon, the member
  can either choose a different HH or different
  plan
• The best option is for the HH and Plan to have a
  contract

26
Outreach and Engagement

• As part of the States 1115 waiver, the Health
  Home development fund requested funds for a
  public education campaign to make it easier for
  outreach partners to engage with potential HH
  members.
• Resources to assist with outreach will be made
  available on the Partner Resources section of the
  HH website.
• The State is finalizing a letter HHs can use as
  part of their engagement materials that explains
  the Health Home program.

27
Outreach and Engagement

• Center for Health Care Strategies (CHCS) with
  support from the New York Health Foundation is
  looking into launching an online community,
• Designed to build on the Learning Collaborative.
• Will provide a forum for online peer-to-peer
  exchange, between in-person Learning
  Collaborative meetings.
• Will allow HH network care management partners to
  share best practices.
• A demonstration of the sites features and
  functionality will occur soon.

28
Outreach and Engagement

• HHs have three months to engage members if after
  three months a member is not found or cannot be
  engaged in active care management the member
  cannot be billed for
• HHs may decide to continue to try and engage a
  member during this non-billable period at their
  discretion. Network partners and lead HHs
  agencies should discuss process.

29
Health Home Services

• All clients who meet HH eligibility criteria can
  receive HH services regardless of the level of
  service intensity.
• HHs are building capacity so members can be
  prioritized using acuity scores.
• Health Homes who determine a member no longer
  needs HH services should discuss, with the
  member, the option of having their care
  management handled by a PCP and/or PCMH as
  appropriate.
• It is the clients choice to opt out or disenroll
  from a HH. At the time the client opts out or
  disenrolls, they should be informed of options to
  join other HHs and told they may return to their
  original HH at any time.

30
Health Home Services

• If a member moves out of a county or borough, HH
  may continue to provide HH services to the
  member, if practicable.
• If the members relocation makes it impractical
  for the HH to continue to provide services, the
  HH is responsible for transferring the members
  assignment to a HH of the members choice.
• HHs are responsible for linking members to all
  the physical, behavioral, and social support
  services a member may need, including vocational
  and housing supports. These resources should be
  included in the HH network and made available.

31
Acuity Scores

• Acuity scores will be recalculated quarterly
  based on updated claims and encounter data.
• HHs and care management partners may not adjust
  acuity scores but the members FACT-GP scores, as
  well as other factors, will be used to adjust an
  individuals acuity score on a prospective basis.
  
• HHs will be able to download the acuity scores
  from the OHIP Data Portal in the near future to
  share with network partners.

32
Acuity Scores

• Claims for members with no established acuity
  score will be set to pend status.
• DOH will receive notification of the pended
  claims and will then submit an average acuity
  score for that member to the payment system.
• There will be a delay in payment, but the acuity
  score will trigger payment of the pended claim.

33
Billing and Rates

• Converting care management partners can bill up
  to the level of their approved legacy slots at
  the legacy rate, and bill for additional or
  expansion slots at the HH rate.
• New clients can be billed at either the legacy
  rate or the HH rate, provided the total number
  of approved legacy slots is not exceeded.
• Clients in a MATS legacy slot must have an SUD
  diagnosis

34
Billing and Rates

• Legacy rates have been extended another year to
  allow converting care management partners time to
  transition to HH services by the end of the
  second year.  
• DOH will monitor funding levels and make an
  assessment as to when legacy rates will convert
  to a blended or HH rate.

35
Billing and Rates

• The HH rates were calculated to allow 6 for
  administrative costs, to be split between HHs and
  MCPs. A larger percentage is justified only if
  HHs and/or MCPs are providing additional support
  or services. Network partners should be asking
  for justification for any additional amount.
• TCMs/MATS bill directly and some have negotiated
  an administrative contribution. DOH is working on
  ways to provide administrative support directly
  to MCPs and TCMs/MATS and will be conducting a
  survey to determine the extent to which these
  arrangements have been negotiated.

36
Billing and Rates

• Providers that have already have Phase 1 rates
  loaded can bill for Phase 2. Phase 2 only
  providers will have to wait until rates are
  loaded to bill for Phase 2.
• It is now anticipated that converting TCM claims
  will be reprocessed in early 2013.
• A client can be referred to a HH based on a
  presumptive assessment. If the assessment reveals
  that the individual does not meet HH criteria,
  outreach and assessment can be billed for that
  month.

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Questions?
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Useful contact information

• Visit the Health Home website http//www.health.n
  y.gov/health_care/medicaid/program/medicaid_health
  _homes/
• Get updates from the Health Homes listserv. To
  subscribe send an email to listserv_at_listserv.hea
  lth.state.ny.us.
• In the body of the message, type SUBSCRIBE
  HHOMES-L YourFirstName YourLastName
• Email questions or comments hh2011_at_health.state.n
  y.us
• Call the Health Home Provider Support Line
  518-473-8864