Draft for Public Comment

NORTH CAROLINA STATE DEMONSTRATION TO INTEGRATE CARE FOR DUAL ELIGIBLE INDIVIDUALS

Submitted to

CENTER FOR MEDICAID AND MEDICARE INNOVATION

Contract Number: HHSM-500-2011-00037C

North Carolina Department of Health and Human Services

Division of Medical Assistance

March 15, 2012

Table of Contents

  1. Executive Summary1
  2. Background 3
  1. Overall Vision and Strategy

ii. Description of population

  1. Care Model Overview12
  1. Proposed Delivery System and Programmatic Elements

ii. Benefit Design

iii. Supplemental Benefits/Supportive Services

iv. Evidence- based practices

v. Description of other Initiatives

  1. Stakeholder Engagement and Beneficiary Protections 19
  1. Internal and External Stakeholder Engagement

ii. Beneficiary Protections

iii. Ongoing Stakeholder Input and Beneficiary Engagement

  1. Financing and Payment 24
  1. State level Payment Reforms

ii. Payment types

  1. Expected Outcomes 24
  1. State’s ability to Monitor, Collect and Track Data on Key Metrics

ii. Potential Targets for Improvement

iii. Impact of Proposed Demonstration

  1. Infrastructure and Implementation27
  1. North Carolina’s Current Capacity

ii. Medicaid/or Medicare Rules that need to be Waived

iii. Plans to Expand to other Populations and /or Service Areas

iv. Overall Implementation Strategy/Timeline

  1. Feasibility and Sustainability 32
  1. Potential Barriers and Challenges to Implementation

ii. Statutory and Regulatory Changes Needed

iii. New State Funding Commitments or Contracting Processes

iv. Scalability and Replicability

  1. Budget Request 32
  2. Additional Documentation32
  3. Interaction with other HHS/CMS Initiatives 33

Appendices

  1. Bibliography
  2. Glossary
  3. Meeting Dates and Agenda
  4. Work group Recommendations
  5. Beneficiary Conversations
  6. Quality Measures
  7. Budget
  8. Work Plan
  1. Executive Summary

North Carolina’s Dual Eligible Beneficiary - Integrated Delivery Model has the triple aims of improving responsiveness to beneficiary goals, improving care quality and achieving shared savings. This new way of doing business is a model designed to meet needs rather than simply provide services; a model where the investment of public funds acknowledges

  • individual differences in the conceptualization of quality of life,
  • the wisdom of preventive services and high quality care,
  • needed supports must vary according to changing goals of individual beneficiaries and their caregivers, and the variation of resources available in communities.

North Carolina’s vision is for a cohesive, equitable and sustainable approach to meeting the needs of dual eligible beneficiaries. It is premised on the knowledge that providing the right care, to the right person, at the right time results in better access and care for us all.

North Carolina has invested in the development and implementation of a statewide medical home and population management strategy through the Community Care of North Carolina (CCNC) Program. The impact of this work on health effectiveness performance measures (HEDIS) places CCNC in the top 10 percent nationally for diabetes, asthma, and heart disease when compared with commercial managed care plan performance in the U.S. Building on the success and infrastructure of CCNC, North Carolina’s integrated delivery model approaches integration through working with beneficiaries as they define and refine their goals and offering medical home supports to assist in the achievement of those goals.

Through the hard work of more than 180 volunteer beneficiaries and stakeholders,North Carolina has fashioned a strategic framework to build on what works well, and to define systemic improvements needed to integrate Medicare and Medicaid services and supports designed to assist dual eligible beneficiaries.

In Phase 1, Medicaid financing will extend medical home offerings to dual eligible beneficiaries in nursing homes and adult care homes. Development will begin on a new process and methodologyfor the independent assessment of need and functional need-based allocation of resources, toward the Phase 2 goal ofreplacing the current FL-2 medical need eligibility determination and level of care determination/placement authorization process. During Phase 1 beneficiaries, providers and other stakeholders will continue to help define the integrated delivery model and refinements, and will develop and implement opportunities for cross-stakeholder education and community-level dialog regarding medical home team dynamics, beneficiary goal setting, and the importance of advance directives specifying personal preferences for physical and mental health care.

As shared savings are made available to North Carolina, Phase 2activity will move the integrated delivery model implementation forward through realignment of financial and regulatory incentivesdesigned to establish new working relationships and information sharing, the broader use of actionable data and capacity building to expand the array of service and support options available to dual eligible beneficiaries with need for assistance from others. Phase 2 efforts will achieve even greater shared savings and furtherreallocation of resources to rectify current inefficiencies created in the health care delivery system.

Table 1: North Carolina Dual Eligible Beneficiary –Integrated Delivery Model

Target Population / Full benefit Dual Eligible beneficiaries (duals) age 21 and older
Total Number of Full Benefit Medicaid-Medicare Enrollees Statewide / 222,753 (Dec 2010, Medicaid)
Total Number of Beneficiaries Eligible for Demonstration / 222,151 (Dec 2010, Medicaid)
Includes: all duals age 21 and older
Excludes: Full benefit duals under 21 years of age (n=455) & full benefit duals incarcerated with suspended Medicaid benefits (n=141)
Geographic Service Area / Statewide, includes all 100 counties of North Carolina
Summary of Covered Benefits / Medicaid covered services
Medicare Part A, B and D covered services
Financing Model / Managed Fee for Service
Summary of Stakeholder Engagement/Input /
  1. Core Leadership Team, representatives from the Divisions of Medical Assistance, Aging and Adult Services, Vocational Rehabilitation, Mental Health/Developmental Disability, and Substance Abuse Services, Public Health and Health Services Regulation, along with Community Care of North Carolina began weekly meetings in July 2011 and currently meet bi-weekly.
  1. Statewide Partners Group, representatives from over 50 partner organizations have met to date on August 18, October 17, and December 16, 2011, February 21 and March 20, 2012.
  1. Work Groups, Phase 1 planning and development groups co-lead by Core Leadership Team members,with broad beneficiary and stakeholder membership, convened in September 2011 and began submitting recommendations in December 2011.
  2. Medical/Health Homes and Population Management
  3. Long Term Services and Supports
  4. Transitions Across Settings and Providers
  5. Behavioral Health Integration
Phase 2 Work Groups - Payment and Delivery System Integration and Community Stakeholder and Beneficiaries Work Group began in late 2011, early 2012 and will continue throughout implementation along with other workgroups.
  1. Beneficiary Conversations, betweenOctober 2011 and February 2012, 9 beneficiary conversations were convened in 8 different communities across the state.
  1. Public Information and Input,: Dual Eligible Planning Website
  1. Public Hearings Dates, March 20 and March 27, 2012.

Proposed Implementation Date / January 2013
  1. Background
  1. Overall vision/rationale for the proposed design

Buoyed by the hope of a federal and state partnership, stakeholders in North Carolina are embracing the opportunity to rethink how best to meet the needs of dual eligible beneficiaries. The integrated delivery model outlined here is the product of more than 180 stakeholders thinking and working together to formulate overarching guidance for North Carolina Medicaid policy.

The vision is for a cohesive, equitable and sustainable approach to meeting the needs of dual eligible beneficiaries. It is premised on the knowledge that providing the right care, to the right person, at the right time results in better access and care for us all. This delivery model approaches integration through working with beneficiaries as they define and refine their goals, and offers medical home supports to assist in the achievement of those goals. When fully implemented all dual eligible beneficiaries, working with their primary care physicians, will have access to quality health care services, support networks, and access to information and resources that build on beneficiaries’ strengths, regardless of their functional capacity, clinical needs, or living arrangement.

Health care and supportive services for dual eligible beneficiaries in North Carolina are often delivered through a complex and fragmented delivery system. Absent an explicit, proactive shared vision, the evolution of policy and program priorities have produced a dizzying array of service systems that fail to meet the needs of those they intend to serve. Furthermore, these systems result in perverse expectations and incentives, making it difficult for well-intentioned providers to deliver the best care. Regulatory and financial interests of providers are in direct conflict with the preferences and clinical best interests of beneficiaries at multiple junctions of these fragmented systems. As a consequence there is a lack of trust and little dialogue between and among beneficiaries, providers and policy makers. The untoward outcomes are beneficiary dissatisfaction, sub-optimal care and inefficient use of public funds. Examples of the misery sustained by beneficiaries and their families, frustrations faced by providers and advocates and examples of wasteful use of public funds are well known to stakeholders from all perspectives.

Over the past 20 years, North Carolina has tackled similar systems realignment through the piloting, development,and implementation of cohesive statewide capacity to:

  • assure children’s access to quality care through development of pediatric medical homes,
  • improve outcomes for Medicaid recipients through extension of medical homes to adults, and
  • improve the quality of care provided for individuals with chronic conditions, targeting chronic diseases such as asthma (in 1998), diabetes (in 2000), and congestive heart failure and chronic care (in 2004/5).

North Carolina has invested in the development and implementation of a statewide medical home and population management strategy through the Community Care of North Carolina (CCNC) Program. The impact of these initiatives on health effectiveness performance measures (HEDIS) place CCNC in the top 10 percent nationally for diabetes, asthma, and heart disease when compared with commercial managed care plan performance in the U.S.

Building on the success and infrastructure of CCNC, in January 2010 eight of the 14 CCNC Networks began focusing on the complex needs of dual eligible beneficiaries through rapid-learning pilots under a Medicare 646 Quality Demonstration Project funded by the Centers for Medicare and Medicaid Services, with approximately 206 practices participating.

The Medicare 646 Quality Demonstration pilots have fueled exploration of new ways to better meet the needs of dual eligible beneficiaries and the integrated delivery model design process. Examples of promising pilot practices being tested include:

  • Clear expectations have been established through collaborative development of acute care transition supports with home health providers using tele-health technology to monitor beneficiaries’ chronic disease self-management activities. Implemented protocols are being refined for structured hand-offs to assure continuity of care when home health services are concluded, home health-owned tele-health technology is removed and primary care medical home teams assume primary responsibility for installation and ongoing monitoring and support for beneficiaries’ chronic disease self-management activities;
  • A primary care practice has extended their Project REACH guided care work to residents of adult care homes (non-medical residential care settings). Through the creation of new relationships, communication materials and educational supports for residents and staff of adult care homes, primary care practices are encouraging residents and staff to use practices’ 24/7 call capacity to reduce the use of emergency department and county ambulance resources for non-urgent conditions;
  • Dialysis nurses and Networks are testing initiatives to encourage patients with kidney insufficiency to pursue outpatient shunt placements. Non-emergent placement is expected to help avert serious health crises and concomitant intensive care hospital stays, and emergency-driven initiation of dialysis.

Premised on the availability and use of actionable data for targeting, the Medicare 646 Quality Demonstration recently completed its second year of operation. Remarkably, this initiative was successful in meeting the quality improvement benchmarks on 14 of the 18 Performance Measures and showed some improvement in 17 of the 18 measures. Hobbled by the absence of Medicare claims data for risk stratification and targeting until month 20, it is not surprising that these pilot efforts have yet to show evidence of anticipated cost-savings. In addition, the program uses an “attributed enrollment” logic which makes it difficult to ensure the benefits inherent in the medical home and population management model.

Integrated Delivery Model Strategic Framework

Beneficiary goal Centered

North Carolina’s delivery model centers on the dynamic goals for quality of life defined by individual beneficiaries, and is designed to build on beneficiaries’ strengths, natural supports, and available community resources. The model’s goal has the triple aims of improving responsiveness to beneficiary goals, improving care quality, and achieving shared savings for reallocation in support of full implementation and refinement of the model and sustainable supports for dual eligible beneficiaries.

This new way of doing business is a model designed to meet needs rather than simply provide services, a model where the default setting of care is private homes; a model where the investment of public funds acknowledge

  • individual differences in the conceptualization of quality of life,
  • the wisdom of preventive services and high quality care, and
  • needed supports must vary according to changing goals of individual beneficiaries and their caregivers, and
  • the variation of resources available in communities.

Building on North Carolina’s Medical Home infrastructure

Building on North Carolina's primary care medical home, managed fee for service structure, and population management infrastructure, this Integrated Delivery Model, when fully implemented, offers all dual eligible beneficiaries the opportunity to enjoy the benefits of primary care led medical homes. Through this team-based approach, beneficiaries will serve as members of a broader group, with professionals and para-professionals whose purpose is to provide services and supports to help the beneficiary articulate and achieve their evolving personal health goals.

The dual eligible delivery model builds on North Carolina’s CCNC program with enhanced quality monitoring. This reporting and shared information capacity was developed in collaboration with primary care providers, hospitals, public health departments and other community organizations. An infrastructure with demonstrated success resulting in improved access, care outcomes and cost efficiencies in meeting the needs of Medicaid recipients. Additional information on the CCNC Networks is included in Section C: Care Model Overview and Section G: Infrastructure and Implementation.

The strategic framework for the new Integrated Delivery Model comprises a series of systemic/structural improvements to better target the use of public funds to meet beneficiaries’ needs and to create incentives for improvements in capacity and accountability on the part of all medical home team members. With full implementation, the model realigns incentives to rectify current inefficiencies created when provider financial goals are in conflict with the achievement of beneficiary goals and evidence-based clinical best-practices. These improvements will be implemented over time with Phase 1 focusing on medical home/population management with emphasis on working with beneficiaries residing in nursing homes and adult care homes. As shared savings are realized, the portion of savings available for reallocation to better meet the needs of dual eligible beneficiaries will be used to incent improved delivery capacity and full implementation.

Implementation Phase 1: At the outset, we will target dual eligible beneficiaries at highest-risk for potentially avoidable use of medical services through development of medical homes for residents of adult care homes and nursing homes. This will bring medication reconciliation and transitional supports to beneficiaries that in turn will reduce adverse drug events, non-urgent use of emergency department and ambulance services and potentially preventable and discretionary hospitalizations. During Implementation Phase 1 a functionalneed-based independent medical eligibility determination and resource allocation methodology will be developed, along with a statewide cross-stakeholder education and community dialog regarding the integrated delivery model, beneficiary goal setting, and the importance of advance directives specifying personal preferences for physical and mental health care. Based on testing currently underway, other Medicare 646 pilot initiatives will be added to the statewide repertoire of Implementation Phase 1 integration responses.

Implementation Phase 2: As shared savings accrue, a yet to be negotiated share will be available to North Carolina to create incentives for improvements in capacity and accountability on the part of all medical home team members for all dual eligible beneficiaries. Incentives for improvements will be driven by tiered per member per month payments, potential regulatory relief, and other shared savings incentive structures activated when providers achieve specified quality and cost targets. At the same time, independent assessment and the need-based resource allocation methodology will be implemented to support greater flexibility in the use of public funds and to enable more innovative and responsive treatment-in-place options for beneficiaries in all living arrangements. These arrangements are expected to further reduce non-urgent emergency department and avoidable hospital use, while improving access to a broader set of home and community-based options. New care-giving solutions will be cultivated by creative team-based medical home support to beneficiaries made possible through access to public funds that can be usedmore flexibly.

Following full implementation we anticipate the eradication of waiting lists for servicesas shared savings are reinvested. In addition, when fully operational, culture changes and realigned financial and regulatory incentives will rectify current inefficiencies created when provider financial goals are in conflict with achievement of beneficiary goals and evidence-based clinical best-practices. Additional detail on implementation phases is presented in Section E: Financing and Payment.