Community Based Organizations are from Venus; Health Care

Organizations are from Mars

MOW Annual Conference August 2015

Sharon R Williams, CEO

Williams Jaxon Consulting, LLC

When Worlds Collide

Policy Catalysts

Older Americans Act, 1965

Social Security Act: Titles III, VII, XVIII and XIX

Americans w/ Disabilities Act, 1973

Rehabilitation Act, 1973

Balanced Budget Act, 1997

Medicare Prescription Drug Improvement and Modernization Act (MMA), 2003

Affordable Care Act, 2010

Medicaid MLTSS rules, 2015

Olmstead Decision

They’ve Been Living Among Us for a While

Medicaid & Medicare managed care reforms have been revolutionizing health care delivery and changing the dynamics of other related industries/systems…

Public Health Institutions

Hospitals

Nursing Homes

Physicians

Now it’s our turn!!!

Why We Must Join Forces With the Klingons

Integrated Care Movement

Triple AIM (ACA)

Improving the experience of care for consumers

Improving the health of populations

Reducing per capita costs of health care

Administrative/Programmatic Simplification

Person Centered Planning

WHO are Your Fellow Space Travelers?

Hospitals

Accountable Care Organizations (ACO)

Insurers/Managed Care Organizations (MCO)

Medicaid Managed Care

Dual Demonstration Contractors

Medicare Advantage

Market Place

Commercial Health Plans

Physician Groups/Federally Qualified Health Centers/Rural Health Centers

Medicaid/Medicare fee-for-service

Others—unions/employers

There IS Common Ground

Quality

Care coordination

Improved consumer outcomes/satisfaction

De-emphasis on institutional care

Cost containment

Utilization of a network delivery system for covered

Federal/State oversight

What Key Objectives are Important to the Aliens?

Improving health outcomes/quality

Improved coordination of care

Decrease gaps in care: behavioral, HCBS & medical

Improve Member Compliance: medication adherence, use of

preventive services & PCP engagement

Reduce avoidable readmissions & emergency room visits

Cost containment/financial metrics

Achieving performance metrics

Member satisfaction/retention

Concepts that May be Alien to Traditional Health Care Organizations

Services that aren't ‘clinical-ized’

Person-centered care planning

In home/community engagement with consumers

Impact of Home and Community Based Services on quality/cost of care

Preparing for Launch

CBOs must develop an intimate understanding of the new CUSTOMERS’ needs, drivers and motivation and provide necessary support/services

Know how your products/services address health organizations' needs:

Do they support contractual/regulatory standards?

Do they address quality of care/health outcomes

Health Employer Data information Set (HEDIS)

Medicare Advantage Model of Care (MOC) or STAR Ratings

Do they impact Pay for Performance (P4P) measures?

Do they impact utilization goals?

Do they impact consumer compliance/satisfaction/retention?

What are the financial benefits?

Value Proposition

HCBS agencies have keen sense of consumers’ community based needs

Direct/personal contact with consumers/boots on the ground

Compliance with the proposed Medicaid MLTSS rules

Preventive engagement, routine monitoring

Trusted and knowledgeable community resource

Cost effective and essential services

Network adequacy/competency

Knowledge IS Power! MOWA/state association resources

CMS Medicaid/Medicare websites

State health care associations—HMO, hospital, providers, etc.

State Medicaid Agency staff/websites

Health care industry local/national training

Alignment with other stakeholders, CILS, AAAs, Assisted Living, Nursing Homes, etc.

Kaiser Foundation, SCAN websites, etc.

References

HEDIS (http://www.ncqa.org/HEDISQualityMeasurement.aspx)

CAHPS (https://cahps.ahrq.gov/)

Medicare STAR Ratings (http://www.cms.gov/Outreach-and-Education/Training/CMSNationalTrainingProgram/Downloads/2013-5-Star-Enrollment-Period-Job-Aid.pdf)

The Commonwealth Fund, Assessing Care Integration for Dual-Eligible Beneficiaries: A Review of Quality Measures Chosen by States in the Financial Alignment Initiative (http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2014/Mar/1724_Zainulbhai_care_integration_dual_eligibles_ib.pdf)

Medicare Shared Savings Program (ACO) Quality Measures and Performance Standards (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Quality_Measures_Standards.html)

Disability Rights Education & Defense Fund with National Senior Citizens Law Center, “A Guide for Advocates: Identifying and Selecting LTSS Outcome Measures” (January 2013)

Health Outcomes Survey (HOS) (www.cms.gov/Medicare)

May The Force Be With You!!!

Thank You