San Diego LTCI Project

1
San Diego LTCI Project

• Timothy C. Schwab M.D.
• CM/IO
• January 12, 2005

2
Meeting Objectives

• Overview of SCAN History
• Overview of Social HMO Model
• Roles of Information Systems
• Physician Network Roles
• What should be measured?

3
Mission and Vision

• SCAN will become a leading geriatric-focused
  health management enterprise in the country. Its
  mission is to continue to find innovative ways to
  enhance seniors ability to manage their health
  and to continue to control where and how they
  live.
• We will achieve this mission by developing
  partnerships that allow us to deliver the right
  healthcare, in the right setting, and at the
  right cost while maximizing the seniors ability
  to remain independent.

4
SCAN History

• 12 Passionate Seniors
• 1977 Long Beach Geriatric Health Care Council
• Jointly developed by the City of Long Beach and
  Andrus Gerontology Center (USC)
• 1978 Senior Care Action Network (SCAN)

5
SCAN History (Programs)

• 1980 MSSP (still largest in state)
• 1982 Selected as Social HMO Site
• 1985 Linkages Program
• 1985 Social HMO Operational
• 1994 SMART CARE (Commercial HMO)
• (Medicaid HMO)

6
SCAN History (Recent Programs)

• ESRD Capitated Demo (pending)
• CM Frail Parents of Disabled Adults
• CM Study of Frail Released Inmates
• CM Older Spanish Speaking Adults with Mental
  Health Issues
• Exploring PACE Affiliation
• San Diego LTCI Program

7
Social HMO

• Goals
• Identify frail
• Coordinate social and medical services in senior
  HMO
• Prevent long term NH placement
• Integrate federal, state, and private funding

8
Social HMO

• Demonstration Waivers
• Funding 100 AAPCC
• NHC paid more / healthy less
• Quque NHC enrollment till 1997
• HCBS benefits only for NHC
• No NH enrollment
• Only enroll over 65 y.o.

9
Social HMO

• Independent Living Power
• Personal Care Coordination
• Homemaker Services
• Personal Care
• Home Delivered Meals
• Respite Care (Home and Institutional)
• Emergency Response System
• Transportation

10
Social HMO

• Mandated Benefits for All Members
• Medicare Benefits
• Pharmacy
• Hearing
• Vision

11
Social HMO

• Operations
• Annual self report assessment
• In home assessment for high risk
• Case manager for NHC with care plan
• All network HMO activities

12
SCAN Health Plan Statistics

MEMBERSHIP
12-04 65,482 65,482 Total
17,806 (27) 17,806 (27) NHC
3,426 (5) 3,426 (5) MediCal
528 (.8) 528 (.8) Institutional
GEOGRAPHY Los Angeles, Orange, Riverside, and San Bernardino Counties Los Angeles, Orange, Riverside, and San Bernardino Counties Los Angeles, Orange, Riverside, and San Bernardino Counties
PROVIDERS Hospitals 85 Physicians (PCPs) 2000 Hospitals 85 Physicians (PCPs) 2000 Hospitals 85 Physicians (PCPs) 2000
NETWORK MODEL HCBS Providers 100 HCBS Providers 100 HCBS Providers 100
13
SCAN Health Plan Statistics

• Average Age 78
• Centenarians 90
• 10th Largest Medicare HMO in country

14
HOS Comparisons 2003 An Older, Frailer
Population
Age Distribution US CA SCAN
65 69 25 20 14
70 74 29 27 24
75 79 23 25 27
80 24 29 36


15
HOS Comparisons 2003 An Older, Frailer
Population
Disabilities US CA SCAN
Bathing 15 16 23
Dressing 12 14 18
Eating 6 6 9
Get in/out chair 28 29 32
Walking 36 37 46
Using Toilet 9 10 12
16
HOS Comparisons 2003 An Older, Frailer
Population
Chronic Conditions Distribution Distribution Distribution
US CA SCAN
0 12 12 8
1 19 20 16
2 21 20 20
3 18 18 17
4 30 29 39
17
Information Systems

• Standard HMO Systems
• Enrollment (Medicare and Medical)
• Eligibility (for all providers and plans)
• Member Services
• Provider Network/ Contract management
• Claims payment
• Pharmacy management

18
Information Systems

• Case Management Systems
• Medical Utilization/ Authorizations
• Screening tools
• Assessment tools
• Wireless for in home use
• Care plan generation

19
Information Systems

• Risk Identification/Stratification
• Targeting for interventions
• Data vault information
• Claims/encounters
• Pharmacy
• Lab results
• Survey results
• Member demographics
• Purchase vs build

20
Information Systems

• Management Tools
• Tracking Metrics
• Decision Support Systems
• Regulatory reporting systems
• Quality measurement reports (HEDIS)

21
Physician Network

• Network vs Direct Contracting
• Credentialing
• Hospital based physicians
• Grievance and appeals processes
• Capitation vs FFS
• Relationship with case managers
• Quality and guideline compliance
• Regulatory compliance (DHS vs CMS)

22
Was it Successful?

• What should be measured?
• Financial?
• Functional?
• Medical?
• Processes?
• Enrollment?
• Satisfaction?