Challenges and Opportunities with Special Needs Populations

Presented by Barbara Otto at Empower 2016 on May 5, 2016

Learn about the challenges and opportunities unique to special needs populations in both Medicare and Medicaid. Barbara discusses next practices for addressing non-clinical services that contribute to successful outcomes of this population: successful engagement strategies for special needs populations; and strategies for integrating social determinants of health into care coordination.

Transcript

1. Barbara Otto CEO, HDA Hosted By
2. Challenges & Opportunities with Special Needs Populations
3. Special Needs Populations: Working Definition 3 *Council on Clinical Affairs, Reference manual Physical, developmental, sensory, behavioral, cognitive or emotional impairment or limiting condition that requires medical management, health care intervention and/or use of specialized services or programs.
4. Special Needs Populations: Challenges 4 Social Needs + Chronic Conditions Increasing Enrollment = Increasing Cost HEDIS & CMS Ratings
5. Health care for special needs populations requires “specialized knowledge acquired by additional training” and care measures “beyond what is considered routine.” * American Association of Persons with Disabilities, 2012 5
8. 8 Much of what affects health occurs outside of the doctor’s office. It’s The 80/20 Rule: Unmet social needs are directly leading to worse health. The problems created by unmet social needs are problems for everyone. Physicians say: County Health Rankings show:
9. 80/20 Rule
10. Critical Piece of Special Needs Care Puzzle Primary Care Acute Care Long-term Care Services & Supports Social Services
11. Nonmedical Services that Benefit Health 11 Social & Economic Factors 40% Health Behaviors 30% Clinical Care 20% Physical Environment 10% Social & Economic Factors 40% Health Behaviors 30% • Housing • Nutrition assistance • Employment counseling • Transportation • Language and literacy training • Legal and financial services • Peer networks • Supports that promote independence and optimal functioning
12. Models States Are Using for Special Needs Populations 12 Accountable Care Organizations Integrated Care Models Fee for Service Full Risk Managed Care Integrates Social Services into Care Model Medically & Socially Complex Populations
13. Medicaid Accountable Care Organizations Center for Health Care Strategies, March 2016
14. Integrated Care Models – Dual Eligibles 14 Kaiser Family Foundation & CMS, Feb. 2015
15. Components of Successful Care Models Care Management/ Coordination Patient Engagement Health Information Financial Alignment  Community Care/Health Teams  Coordination across medical and non-medical settings
16. Next Practice: Community Care Teams Common Attributes Across Models  Comprehensive assessments- beyond clinical needs  Evidenced-based care planning that includes health-related needs & preferences  Coordinates between primary care and community resources (social services)  In person, face to face contact
17. ACO Models - CCT Models & Integrated Social Services Oregon: Coordinated Care Organizations (CCOs) 17 Colorado: Regional Care Collaborative Organizations (RCCOs)
18. Components of Successful Care Models Care Management/ Coordination Patient Engagement Health Information Financial Alignment  Community Care/Health Teams  Coordination across medical and non-medical settings  Shared Decision Making  Inclusion of Care Givers
19. Structural & Behavioral Barriers to Patient Engagement Passive v. Active • Defer to “specialists”, often without Primary Care Physicians • Conditioned to “accepting” medical procedures and medication • Social Services and programs not well integrated with Medicaid & Medicare – often involve “hoops”
20. Patient Engagement Improves Outcomes 20
21. 21 Strategies to Engage Special Needs Populations Shared Decision Making Health Coaching Peer Supports Patient Empower- ment Inclusion of Family Care Givers
22. Care Models with Next Practice for Stakeholder Engagement Processes • Multi-sector stakeholder engagement • Consumers representative of patient population • Patient advocacy/consumer groups • Health plans • Community based social services providers – food assistance, income supports, vocational services, cultural organizations and housing services • Government entities; and • Health care providers 22
23. Components of Successful Care Models Care Management/ Coordination Patient Engagement Health Information Financial Alignment  Community Care/Health Teams  Coordination across medical and non-medical settings  Shared Decision Making  Inclusion of Care Givers  Track clinical & non-clinical encounters  Data sharing across providers
24. Data Sharing & Analytics Health Information Track Encounters ID Shared Patients Clients Communication Across Providers Quality Measures Performance Measures Example:
25. Components of Successful Care Models Care Management/ Coordination Patient Engagement Health Information Financial Alignment  Community Care/Health Teams  Coordination across medical and non-medical settings  Shared Decision Making  Inclusion of Care Givers  Track clinical & non-clinical encounters  Data sharing across providers  Value based payment models  Braiding & blending of dollars
26. Payment Models for Integrating Non-clinical Services Upfront Grants Enhanced PMPM Shared Savings Global Payments Fee for Service to Full Risk Managed Care
27. Fiscal Levers for Integrating Social Services Medicare/ Medicaid Other Public $ Grant or Privately Funded Housing √ √ Nutrition Assistance √ Employment √ √ √ Transportation √ √ √ Legal & Financial √ √ Language & Literacy √ Peer Networks √ √ 27 Braid and blend federal, state and grant funding streams
28. For More Information: 28 Barbara Otto, HDA botto@hdadvocates.org @BarbAOtto We work to eliminate economic, social and structural barriers to better health outcomes. Through expert analysis, advocacy and professional training, we make systems and policies work smarter for payers and patients alike. 25 Years of Change That Matters
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