Lifemark Long Term Care Experience

December 15, 1999

The Lifemark Mission

Through innovative care management services and technology offerings, Lifemark strives to create fundamental change in the well being of vulnerable, frail, elderly and chronically ill people.

Locations Phoenix, AZ (Corporate Office) Albuquerque, NM Fort Smith, AR Honolulu, HI Houston, TX Indianapolis, IN Lansing, MI San Diego, CA

LIFEMARK CORPORATION

Care Management Strategies

for “At Risk” Populations

December 1999

Aging Population

Longer Life Expectancies

Prevalence of Chronic Conditions

Complex BenefitCoordination

Why is Long Term Care (LTC) a heightened issue?

The Coordinated ModelIntegrated Services

Long Term Care Home and Community Based

Services Behavioral Health Medical Care Services:

Inpatient/Outpatient care Physician Lab/Radiology EPSDT Transportation Ancillary Services

Specialist

Pharmacy

DME Therapie

s

“Single Entity”

LTC

HCBS

BehavioralHealth

Medical Care Svcs

Coordinated Medicare fee-for-service and/or Medicare HMO Benefits

Coordinated LTC ModelFull Continuum of Placement Options

MostRestrictive

LeastRestrictive

Assisted Living/Residential Care

Adult FosterCare Home

AdultCareHome

Home orApartment

Specialty Unitwithin a

nursing facility

SkilledNursing Facility

Patient Centered CareCase Manager’s Role

Nurses, Social Workers, or those with 2 years case management experience

Coordinator, facilitator, investigator, service broker, liaison, and advocate who is empowered to authorize and verify services

Leads team of decision makers

Patient

Family orRepresentative

Case Manager

PCP

Closely linked to PCP, patient and family

Care Management SystemsInitial In-Depth Assessment

Highly automated using laptop computers

Performed within five days of enrollment

Current/previous medical status Socioeconomic profile Psychological assessment Functional assessment (ADLs) Develop multiple alternative care

plans for service(s), placement, provider, and/or reassessment schedule

Level of care determination Perform cost effectiveness study Initiate/authorize:

Formal service plan Actual placement Establish measurable goals

I N I T I A L A S S E S S M E N T

Location of Face-to-Face visit___________________________ Other__________________________

TDHS Care Plan received No *Yes

Member Name______________________________________ ID#____________________________

Eligibility Date_______________ Age______ Sex M / F Primary Language________________

Responsible Party___________________________________ Relationship_____________________

Party’s address_____________________________________ Phone #_________________________

Primary Dx________________________________________ Secondary Dx____________________

BH Dx(s)__________________________________________ Dx of ALZ______________________

Dementia_____________ OBS____________ HMO Blue PCP_______________________________

Previous Phy or Medicare Risk PCP__________________________________ Last MD Visit_____________

Last Hospitalization__________________________________________________________________________

PART 1 Orientation / Psycho SocialPrimary Lifetime Residence / Area_____________________________________________________

Previous Occupation_____________________________ M / W / S / D # of Children________

Orientation conducted: No

Yes Via Phone On-site Other____________________

Receipt Enrollment Orientation Packet Verified: Yes No

Explanation of following:

Role of PCP Selection and Change Options

How to access care Beh/Substance Services

Why Interdisciplinary Team may be convened

Emergency Care Access in Plan Out of Plan Member s’ Services Role

Complaint System Filing Member Rights/Responsibilities

Options for Disenrollment

Care One

Care Manager Scope of Authorization

LTC Services/Placements include Nursing Facility Assisted Living/Personal Care Home/Adult Foster Care Adult Day Care Community based alternatives Medical Supplies/DME Value Added Services

Home Services Personal, Attendant, and Chore Services Skilled Home Health Care/Short term therapy Emergency Response Systems Meals on Wheels Respite

Patient-Centered CareCritical Elements to Success

Develop intense, fully integrated care management system to consolidate funding, limit fragmentation/duplication, monitor quality, outcomes, clinical utilization and costs

Establish an HCBS infrastructure and expand covered services to include full menu of HCBS services

Perform outcomes, placement and cost comparisons for effective service alternatives

Arizona/Texas LTC Program(s)

State Medicaid Agency Retains Responsibility For:

Determining Member Program Eligibility (Both Financial and Medical)

Health Plan Assignment HCFA Waiver/State Regulations Program Compliance Monitoring/Auditing RFP Development, Scoring and Awards

Ventana Health SystemsA Wholly Owned Subsidiary of Lifemark Corporation

Arizona Health Care Cost Containment Systems’ Long Term Care System (ALTCS) program contractor since January 1989

Serving the most chronically ill of the Aged, Blind and Disabled at-risk for nursing home placement

Providing services in 9 rural counties of Arizona Pre-paid, capitated health plan for 1,900+ LTC members A fully integrated services approach coordinating institutional, home

and community based services, behavioral health, pharmacy and medical care services

Member satisfaction indicates improved functionality and quality of life

Arizona

0102030405060708090

100

1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Perc

en

tag

e %

Institutional HCBS

Percentage of Lifemark/Ventana Health Plan Members inInstitutional vs. HCBS Settings

Source: Ventana Health Systems Claims and utilization data.

Impact on Member PlacementMovement Toward Home and Community Based Services

Ventana Health SystemsA Wholly Owned Subsidiary of Lifemark Corporation

Caseload limits are (case manager-to-member ratios):

1/48 HCBS, acute care/hospice members (visits every 90 days) 1/120 nursing facility members (visits every 180 days) One case manager for mixed caseload of approximately 96 clients (nursing

facility and HCBS) Ventilator dependent members case managed based on setting

Subset of Clinical quality outcomes are monitored by measuring: Influenza Sacral/Coccygeal pressure ulcers Hospitalization and emergency room utilization Activities of Daily Living Fractures related to falls

Arizona

Pilot demonstration started in Harris County (Houston), Texas January 1998

Integrates acute medical, LTC, behavioral and community based services into a managed care delivery system

Emphasis on least restrictive setting and intensive care coordination Three health plans awarded contracts, covering over 52,000 members Primarily mandatory enrollment Lifemark manages over 19,700 LTC (NF and CBA) and SSI (ABD)

recipients - the largest in the STAR+PLUS program

HMO BLUE/STAR+PLUS100% Administered Managed by Lifemark Corporation

Texas

HMO BLUE/STAR+PLUSManaged by Lifemark Corporation

Caseload limits are determined by need (case manager/member ratios):

Level I - 1/2,500 members

Level II - 1/250 members

Level III - 1/100 members

Level IV - 1/30-60 members

Current clinical quality outcome studies are: Depression Childhood asthma Adult diabetes Breast cancer screening

Texas