2019 AGENDA

Continental Breakfast

Chairperson's Welcome

Changing the Direction of Medicaid -the Trusted Way: New Innovative Approaches to Care Coordination

• Medicaid today (an overview of where we are)
• New Innovative Approaches
• The Trusted Way Our ROI

Readmission Prevention Using an Alternative Payment Model: The Independent Care Health Plan Case Study

• How redefining Readmission Prevention can lead to more effective and more sustainable solutions
• How some Health Systems' conflict of interest impact readmission prevention programs
• How an Alternative Payment Model can be a low-cost intervention that drives improvement in health outcomes
• How "discharge to home" needs to be re-examined

Using Data to Tailor Care Coordination Programs to Member Needs: Leveraging Health Assessments and Claims Data to Identify Those Most at Risk and Target Resources Accordingly

Morning Refreshment Break

Assembling an Interdisciplinary Team to Provide Care Coordination: Integrating Plan, Provider and Community Resources for Optimal Results

• Ways to promote the clinical expertise of your pharmacy team and the value the team brings to other departments in your company
• How to market your pharmacy department to your outside partners
• Member education on the value of MTM
• Benefits of using a MTM hybrid approach with your PBM

Adopting a Community Health Worker (CHW) Model: Leveraging CHW Interventions as a Resource to Improve Outcomes Among High-Risk Populations

• A look into the [email protected] program and the approach of the community health worker role as a fundamental part of the solution
• An overview of the interventions of the community health worker and the barriers they encounter while trying to make a positive impact on patients
• How a team approach can positively improve health outcomes for high-risk patients within a population health setting

Designing Coordinated Whole-Person Care that Addresses Social Determinants of Health: Integrating Non-Medical Health Factors to Promote Value-Based Care

• How to design and implement Social Determinant of Health interventions addressing economic stability, housing, and food access to improve health outcomes
• Engaging effectively with community partners for programs that advance the mission of both organizations
• Internally developing a matrix organization to holistically coordinate care and interventions for members

Luncheon

Panel Discussion :Improving Care Transitions Between Settings to Reduce Avoidable Readmissions and Improve Outcomes

Moderator:

Panelists:

Reducing Readmissions and Avoidable ED Visits: A Comparison of In-home Programs Targeting Multiple Populations with Similar Yet Unique Needs

• Why utilize in-home models?
• Why Area Agency on Aging?
• Why Interim?
• Describe Processes
• Describe collaboration across continuum
• Outcomes
• Lessons Learned

Leveraging Digital Care Coordination Tools and Multichannel Outreach to Improve Health Outcomes and the Member Experience

Afternoon Refreshment Break

Conducting Comprehensive Care Coordination Efforts for LTSS Including Health and Social Services

This presentation will share a macro approach to meeting the diverse and individualized health needs of Seniors and Persons with Disabilities, focusing on:

• Healthcare as a Catalyst for Social Innovation
• Weaving the Safety Net by Defragmenting Medicaid Waiver Programs (LTSS)
• Developing a Strategic Community Resource Program

Driving Medical Home Transformation: Supporting the PCMH Model with Incentive Programs and Online Tools

The Maryland Health Care Commission (MHCC) conducted a Maryland Multi-Payor Patient Centered Medical Home Program (MMPP) pilot. The MMPP pilot was a 5-year program testing the effectiveness of the patient-centered medical home (PCMH) model of primary care in 52 Maryland practices. A patient centered medical home is defined in Maryland law as a primary care practice organized to provide a first, coordinated, ongoing, and comprehensive source of care to patients to: foster a partnership with a qualifying individual; coordinate health care services for a qualifying individual; and exchange medical information with carriers, other providers, and qualifying individuals. Learning lessons from the pilot inform the development of value-based care delivery models in Maryland.

• A unique feature of the MMPP pilot as compared to many other PCMH programs nationally is that Maryland’s PCMH law required the five largest State-regulated health insurance carriers to financially support the program by providing up-front and incentive payments to qualifying MMPP practices. Other state and federal payers, including Medicaid and TRICARE voluntarily joined the program.
• Practices had access to an online portal that contained program level reports, practice updates, and a quality measure reporting portal. They also had access to daily electronic reports showing patients who had a hospital or ED admission anywhere in the State through the State-designated health information exchange, CRISP.
• The practices cited implementation and improvement of EHR systems as an important aspect of improved care coordination. While establishing and optimizing EHR systems has been challenging for most practices, they have been instrumental in increasing coordination across facilities and within the practice. Using the EHR system to monitor aggregate and patient- level outcomes provided a platform to coordinate practice-wide activities and communicate about patient follow-up and care plans.

Innovations in Oregon's CCO System

• Brief overview of Oregon's Medicaid Waiver & CCO System
• Presentation on the structure of the PacificSource Regional CCO Model including our unique partnership for community governance
• Strategies for engaging Medicaid members in the transformation of healthcare
• Reinvesting funding across communities to improve population health
• Specific strategies to reduce ED utilization

Cocktail Reception

Continental Breakfast

Community Health Innovation Region Model to Address Emergency Department Utilization and the Social Determinants of Health

• Collaboration between a community backbone organization, Patient Centered Medical Home (PCMH) practices, and Medicaid Health Plans to identify high, inappropriate, and preventable Emergency Department utilizers
• Implementing a community-wide strategy to address the Social Determinants of Health
• Utilizing community-based social workers, nurses, and community health workers to facilitate clinical community linkages for Medicaid patients
• Leveraging health informatics tools to facilitate clinical and community service referrals between healthcare and non-healthcare entities

Taking a Value-Added Approach to Opioid Addiction: Partnering with Providers to Identify Misuse, Reduce Opioid Prescribing, and Treat Opioid Use Disorder as a Chronic Condition

Opioid utilization management aligned with the CDC Guideline for Prescribing Opioids for Chronic Pain was implemented on February 1, 2019 for Commercial and Medicaid Members. Prescribers who believe their patients should exceed CDC guideline recommendations were required to submit documentation supporting these doses. This presentation will discuss:

• The impact this strategy had on members, prescribers and the health plan
• Clinical outcomes as well as initial administrative burden on the plan, providers and members
• Including interdisciplinary teams during and after the implementation of an opioid utilization management strategy
• Lessons learned during the implementation of this strategy

Payer-Provider Collaboration- Best Practices from Gateway Health Plan

• Innovative approach to Care Coordination for the Medicaid population
• Data sources utilized to identify participant
• Using motivational interviewing and member centered care planning
• Drilling down on Social Determinants of Health
• Improving health outcomes and achieving return on investment

Reducing Avoidable Admissions & Readmissions Through Field & Traditional Care Management Models

Reducing avoidable utilization in challenging, hard-to-engage populations requires non- traditional approaches to member identification and ongoing member engagement.  In this session, Mr. Aminzadeh of Decision Point will discuss:

• Machine learning and unstructured approaches to member identification
• Role of social determinants of health in identifying risk
• Challenges of deploying of field-based care management programs & lessons learned
• Effectiveness of programs in reducing avoidable utilization

Morning Refreshment Break

Integrating Palliative Care into the Continuum of Care: Establishing a Community- Based Model

Developing Strategies for Driving Down ER Utilization---How Priority Health Used Embedded Community Health Workers and Other Resources to Optimize Outcomes

Historically, engagement with the Medicaid population has been via mail or telephonically, with limited success. We successfully engage approximately 33% of our population this way. We now realize the importance of face to face engagement with some of our most challenging members, including members who are now homeless, members who are disengaged from their medical care providers, parents managing the care of a chronically ill child or for members utilizing the emergency room frequently.
We know that Medicaid members utilize the Emergency Room for both primary and urgent care as well as secondary gain. Trust, warmth, security, food and community are all “other” reasons why Medicaid members are in our emergency rooms. We also know that Medicaid members frequent the ER more frequently than our Medicare or Commercial members. Our solution: A Community Health Worker in the Emergency Room setting. Our Community Health Workers are from the communities in which our members live. They are a trusted face of Health Plan and can facilitate that face to face engagement. Being able to meet the member, where they are, in the emergency room, at the time of the visit, has a far greater impact in addressing whatever issues the member may have and in redirecting the member back to their Primary Care Provider than any telephonic intervention can have some days or weeks after the event. And the early results are promising!!

Integrating Clinical Pharmacy Post-Discharge Medication Reconciliation into the Transition of Care Process to Improve Quality and Reduce Readmissions in High Risk Medicare Advantage Patients

Hospital readmissions are estimated to cost 50.7 billion dollars annually and 29.6 billion for Medicare alone. Medication-related adverse events occur in an estimated 20% of patients after discharge. Pharmacist post-discharge medication reconciliation has been proposed as a potential way to identify and reduce drug related problems and in turn readmissions. Additionally, this patient touchpoint gives pharmacists an opportunity to close gaps in care related to Medicare Star Measures such as MTM, statin use in persons with diabetes and others. Objectives of this presentation:

• Describe the need to focus on reducing preventable readmissions
• Recognize the role of clinical pharmacists in post-discharge medication reconciliation and review
• Explain steps taken and key learnings from starting a post-discharge medication reconciliation program
• Identify how a post-discharge medication reconciliation program can impact Medicare Star Measures

Conclusion of Conference