Social Work Over the Rainbow ... - LeadingAge New York Work...11/9/2015 1 Social Work Over the Rainbow Elliott Frost Leading Age NY Discussion Points Proposed new CMS regulations Survey

11/9/2015

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Social Work Over the Rainbow

Elliott Frost

Leading Age NY

Discussion Points

Proposed new CMS regulations

Survey

Focused survey initiatives

Incident reporting

Managed care

Other issues

Reasons for Regulatory Revisions

Increased acuity

Increase in need for behavioral health services

Emphasis on resident-centered care

Major CMS Initiatives

Reduce unnecessary readmissions

Reduce Healthcare Associated Infections (HAI)

Reduce use of antipsychotic medications

Improve behavioral healthcare

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Major Themes

Facility-based assessment

Competency-based approach

Incorporation of previous regulations and directives

Improved readability

Restructuring of current regulations

Creation of new requirements

Implementation of legislation

Facility Responsibilities (New)

Focuses on facility responsibilities (protecting the residents’ rights, enhancing quality of life). This section parallels many residents’ rights provisions.

Visitation: Would establish open visitation, similar to the hospital conditions of participation.

Abuse/Neglect/Exploitation (§483.12): Would revise “Resident behavior and facility practices,” to “Freedom from abuse, neglect, and exploitation”; and

Prohibit employment of individuals with disciplinary actions against their professional license by a state licensure body following a finding of abuse, neglect, mistreatment, or misappropriation of property.

Require implementation of written policies and procedures that prohibit and prevent abuse, neglect, mistreatment and/or misappropriation of property.

Facility Responsibilities

Adds a new term "exploitation", that is added to address circumstances that may not rise to the level of abuse or neglect, but would nonetheless be prohibited (the unfair treatment or use of a resident or the taking of a selfish or unfair advantage of a resident for personal gain, through manipulation, intimidation, threats or coercion).

Comprehensive Person-Centered Care Planning (New)

Interdisciplinary Team (IDT): Would add a nurse aide, food and nutrition services, and a social worker to the IDT that develops the comprehensive care plan.

Comprehensive Care Plan: Would require written explanation in the medical record if participation of the resident and their resident representative is determined not practicable .

Would require development of a baseline care plan for each resident within 48 hours of admission, including instructions needed to provide effective and person-centered care meeting professional standards.

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Behavioral Health (New)

Would focus on provision of necessary behavioral health care and services to residents in accordance with their comprehensive assessment and plan of care.

Would require staff to have appropriate competencies to provide behavioral health care and services, including care of residents with mental and psychosocial illnesses and implementing non-pharmacological interventions.

CMS notes in the Preamble that reference to mental health/illness includes substance abuse disorders.

Would add “gerontology” bachelor’s degree to the list of acceptable minimum social worker educational requirements. .

Top Ten Most Frequently Cited Deficiencies

• LeadingAge NY analysis of OSCAR data• Health surveys only• Standard surveys only (i.e., complaint

survey deficiencies excluded) • 15 month period: March 2014 – May

2015• Top 10 statewide and by area office

For more information on survey and assistance in addressing and preventing deficiencies contact Elliott Frost, [email protected]

Top Ten Most Frequently Cited Deficiencies –STATEWIDE

Top Ten Most Frequently Cited Deficiencies – Long Island

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Top Ten Most Frequently Cited Deficiencies – New York City

Top Ten Most Frequently Cited Deficiencies – Hudson Valley

Top Ten Most Frequently Cited Deficiencies –Northeastern NY

Top Ten Most Frequently Cited Deficiencies – Central NY

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Top Ten Most Frequently Cited Deficiencies – Rochester Region

Top Ten Most Frequently Cited Deficiencies – Buffalo Region

Citation Spotlight:

- Provide medically-related social services to help each resident achieve the highest possible quality of life (F250)

- Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances (F319)

- Periodic Health surveys (complaint surveys excluded)

- 15 month period ending July 2015

- Compared to previous 15 month period3,751

3,722

43

39

15 Months Ending July 2015

15 Months Ending April2014

F250 Citations All Citations

All Deficiencies and Med-related Social Services (F250) Citations: Most Recent 15 Month Period vs. Previous 15 Months

Vast majority of F250 citations were level D, with little year-to-year change

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Medically-Related Social Services (F250) Citations: Most Recent 15 Month Period vs. Previous 15 Months, by Region

2 2

10

1

8

11

553

22

1 1

9

2

0

5

10

15

20

25

15 Months Ending in Apr 2014 15 Months Ending July 2015

3,751

3,722

28

25

15 Months Ending May 2015

15 Months Ending Feb 2014

F319 Citations All Citations

All Deficiencies and Treatment for Psychosocial Problems (F319): Most Recent 15 Month Period vs. Previous 15 Months

Vast majority of F319 citations were level D, with little year-to-year change

Treatment for Psychosocial Problems (F219) Citations: Most Recent 15 Month Period vs. Previous 15 Months, by Region

3

0

14

1

4

12

4

1

13

5

1 1

3

0

2

4

6

8

10

12

14

16

15 Months Ending Apr 2014 15 Months Ending in July 2015

F250

Based on observation, record review, and interviews conducted during the standard survey it was determined for 4 of 17 residents (Residents #3, 5, 12, and 15) reviewed for social services, the facility did not ensure residents received medically-related social services to attain or maintain the highest practicable mental and psychosocial well-being. Specifically, for Residents #3, 5, 12 and 15 social services did not develop and implement a plan to meet their psychosocial and emotional needs after exhibiting adjustment difficulties, including agitation, anxiety and depressive symptoms.

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F250

Based on observation, record review, and interview conducted during the standard survey, it was determined for 3 of 4 residents (Resident #5, 8 and 10) reviewed for social services, the facility did not provide medically-related social services to attain or maintain residents highest practicable physical, mental and psychosocial well-being. Specifically, Resident #5, 8 and 10 were transferred from a long term care facility in the Syracuse area and expressed a desire to return to the Syracuse area. There was no evidence social services followed up regarding the residents' expressed wishes.

F250

Based on observation, record review, and interview, the facility did not ensure that medically-related social services to attain or maintain the highest physical, mental, and psychosocial well-being of each resident were provided. Specifically, social services did not assist residents in obtaining clothing. This was evident for 2 of 2 residents reviewed for Social Services (Resident #21 and #163).

F250

Based on interviews and record reviews, it was determined that for one (Resident #4) of two residents reviewed for social services, the facility did not provide the necessary medically related social services to attain or maintain the highest practicable mental and psychosocial well-being of each resident. The issue involved the lack of timely social work intervention for a resident with documented signs of depression (Resident #4).

F250

Based on resident and staff interviews during the partially extended recertification survey, the facility did not provide medically-related social services for each resident. Specifically, for eight (8) resident's (#'s 37, 40, 56, 57, 61, 91, 94, and 101) of eight (8) residents interviewed during the Group Interview, the Social Work department did not make referrals and obtain services for absentee ballots for the residents.

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Dementia Pilot Survey

Examine the process for prescribing antipsychotic medication

Examine dementia care practices in nursing homes

Gain new insights about surveyor knowledge, skills and attitudes

Determine ways that the current survey process may be streamlined to more efficiently and accurately identify and cite deficient practice as well as to recognize successful dementia care programs.

Dementia Pilot

Most State surveyors said that they were able to identify deficient practices related to dementia care and unnecessary drugs. In some cases, the teams conducting focused Dementia Care surveys found deficient practices just a few weeks after a standard survey team had been in the facility and had not cited deficiencies related to dementia care.

The majority of surveyors believe that a more detailed evaluation of dementia care practices (some questions from the dementia care focused survey pilot tools and processes) should be integrated into the annual survey process; however a majority also suggested that the focused survey should remain as a stand-alone survey to be conducted at the discretion of the SA or CMS

Dementia Survey

CMS has revised the dementia care focused survey process and plans to apply the revised version in both traditional and QIS States. CMS also plans to use a streamlined version of the dementia care focused worksheets and processes during complaint surveys in several States, to determine if this is an effective means of integrating a focus on dementia care into State Survey Agencies activities.

CMS is in discussions with the Central Office training division and State Agency training coordinators on ways to integrate the valuable experiential learning into ongoing orientation and other training efforts.

MDS Focus Survey

Focus on Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and will evaluate the MDS assessments and the associated care planning for nursing facility residents.

Of the 25 facilities surveyed in the pilot, 24 received deficiencies for errors related to MDS coding

Severity of injury associated with falls.

Pressure ulcer status.

Restraint use.

Late loss activities of daily living (ADL) status.

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F309

Interpretive Guidelines §483.25

In any instance in which there has been a lack of improvement or a decline, the survey team must determine if the occurrence was unavoidable or avoidable. A determination of unavoidable decline or failure to reach highest practicable well-being may be made only if all of the following are present:

An accurate and complete assessment (see §483.20);

A care plan that is implemented consistently and based on information from the assessment; and

Evaluation of the results of the interventions and revising the interventions as necessary.

National Partnership

The National Partnership seeks to optimize quality of life for residents in America’s nursing homes by improving comprehensive approaches to the psychosocial and behavioral health needs of all residents, especially those with dementia. The Partnership promotes the three “R’s”

Rethink • rethink our approach to dementia care

Reconnect • reconnect with residents via person-centered care practices

Restore • restore good health and quality of life

CMS announces new goal to reduce use of antipsychotic medications to long-stay nursing home residents by 25% by end of 2015, 30% by end of 2016

Incident Reporting Manual

Clarify terms

Provide clearer examples

Assist in identifying incidents that need to be reported

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Contact

Elliott Frost [email protected]

(518) 867-8832

A word about Managed Care …

Managed Care Transition-Lessons Learned So Far …

Social Work Over the Rainbow

Monday, November 16, 2015

Bolton Landing, NY

4:15 – 5:30 p.m.

Presented by:

Patrick Cucinelli, MBA, LNHA, EMT


Federal Background – The Affordable Care Act

State Initiative – Medicaid Redesign

Medicaid Redesign

Managed Care & Plans: Defining Features

Medicaid Waiver and DSRIP

Critical Issues for Discussion

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The most important slide of all time:• ACO = Accountable Care Organization – a product of the Affordable Care Act

• BHO = Behavioral Health Organization / Utilization Management focus

• BIP = Balance Incentive Program

• DISCO = Developmental Disability Individual Service Care Organization

• DSRIP = Delivery System Reform Incentive Payment

• ERF = Elliott R Frost (answers to all your social work questons)

• FFS = Fee for Service

• FIDA = Fully Integrated Duals Advantage

• HARP = Health and Recovery Plan (set of behavioral services available from an MCO)

• Health Homes = Care Coordination / Management on a regional basis with integration of provider networks

• MAP (Medicaid Advantage Plus) = combination of Medicaid managed long term care plan and Medicare Advantage plan

• MCO = Managed Care Organization a.k.a. Health Plan

• Medicaid Advantage = Medicaid managed care for dual eligible not in need of LTC

• Medicare Advantage = Medicare managed care

• MLTC = Managed Long-Term Care Plan

• MMCP = Mainstream Medicaid Managed Care Plan

• PACE Program = Program for All-Inclusive Care for the Elderly

• VAP = Vital Access Provider 41


The ACA creates incentives to move away from traditional FFS to new payment arrangements, including managed care, bundled payments, value based purchasing, and accountable care organizations.


NYS Medicaid Redesign Team

Add more services to managed care benefits

Require more recipients to join “mainstream” plans

Require most HCBS recipients to join MLTC plans

Enroll certain dual eligibles in integrated Medicare/ Medicaid managed care starting in 2014

Use health homes, medical homes and ACOs to coordinate care and network services

Enroll all Medicaid recipients in managed care/ coordinated care models within 5 years


Achieve the federal “triple aim” Improve Population health

Improved care (Quality/Satisfaction)

Lower/Control cost

Reduce uncertainty and risk for the state Contract with, and pay, fewer entities “Care management for all” Integrate Medicaid with Medicare Access federal funding

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Defining Features of Managed Care

Added benefits or lower cost- sharing

Care coordination and management

Preventative health benefits

Capitation and risk

Single point of contact

Provider network


Priorities

Reduce Uninsured

Reduce Medicaid eligible

Encourage participation in the NY Health Exchange (NY State of Health) for individuals and small businesses

Measure and constantly strive to improve patient quality of care and satisfaction

State or join care coordination organizations to improve quality, lower costs, and increase reimbursement

Accountable care organizations

Medical homes

Health homes

Prepare to invest in technology to

Measure quality of care

Measure costs

Share information with other coordination organizations

Managed Care Changes Incentives

Party Issue Fee-for-Service Managed Care

ConsumerServices

Wide provider choice; minimal limits on services; limited care coordination

Provider choice limited; service limits; focus on care coordination

FinancesVarying levels of cost sharing

Varying levels of cost sharing and incentives

Health care provider

ServicesDriven by provider assessment of need, subject to review

Usually determined and authorized by plan

FinancesState-set reimbursement, volume-driven

Rate negotiated with plan, volume controlled

PayerServices

Scope driven by federal/ state laws, regs and policy

Scope driven by contract with managed care plan

FinancesTotal paid = rate times service utilization

Total paid = PMPM times # of enrollees 47

Types of Managed Care Plans

1. Commercial Managed Care

Preferred provider organizations

Health Maintenance Organizations

Exclusive Provider Organizations

2. Medicare Managed Care

Medicare Advantage

Medicare special needs plans (e.g., Evercare)

3. Medicaid Managed Care◦ Mainstream Medicaid Managed Care◦ Family Health Plus/Child Health Plus◦ Healthy New York◦ HIV Special Needs Plans (HIV-SNPs)◦ Managed Long Term Care (MLTC)

4. Medicaid and Medicare (Dual eligibles)◦ Medicaid Advantage (Dual special needs & Institutional special needs plans)◦ Medicaid Advantage Plus (MAP)◦ Programs of All-Inclusive Care for the Elderly (PACE)◦ Managed Long Term Care (MLTC)◦ Fully Integrated Duals Advantage (FIDA)

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Partially Capitated131,280

Total Enrollees Statewide150,202

Number of Plans Statewide Actively Enrolling 66

Partially

Capitated 32

Program of All-Inclusive Care for the Elderly (PACE) 8

Medicaid Advantage Plus (MAP) 8

*Based on the September 2015 managed care enrollment report

2 Serving NYC

24 Serving NYC

All Serving NYC

MLTC Statewide Enrollment – September 2015*Source: NYS DOH

FIDA 18Demonstration counties only

49

FIDA 7,280

FIDA Enrollment Update – September 1, 2015

2

FIDAEnrollment

NY Medicaid Choice Calls

Received

Total Opt-Outs

7,280 96,976 57,375

Critical Issue - Managed Care Changes Incentives

Understanding how managed care organizations, the DOH, Maximus and the providers interact.

• All referrals will go through Maximus.

• The plans will play a role in selecting providers.

• Enrollees can change plans “midstream.”

• All payments will flow through the plans.

• Opportunity for one off contracts.

• Networks become very important.

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Conflict-Free Evaluation and Enrollment Center (CFEEC)

The NYS DOH has partnered with MAXIMUS to provide all activities related to the CFEEC including initial evaluations to determine if a consumer is eligible for Community Based Long Term Care (CBLTC) for more than 120 days. The CFEEC will be responsible for providing conflict-free determinations by completing the Uniform Assessment System (UAS) for consumers in need of care.

CFEEC evaluations are conducted in the home (includes hospital or nursing home) by a Registered Nurse for new to service individuals and all other related activities are conducted in writing or by phone.

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Are you in the network?

New York is not an “any willing provider” state, therefore a managed care organization can choose to exclude a provider from its network for any reason.

Number of contracts to manage and number of available plans in an area.

New York is not an “any willing provider” state, therefore a managed care organization can choose to exclude a provider from its network for any reason.

Number of contracts to manage and number of available plans in an area.

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Critical Issue - Networks

Providers need to be making strategic decisions about which plan networks to join.

• Administrative work in managing contract.

• Value of being in a network.

• Cost of not being in a network.

• Role and responsibilities of various plans and billing practices.

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Critical Issue: DSRIP

DSRIP, like managed care, will significantly impact how the overall system functions and this will eventually impact provider relationships and how residents/patients receive care.

For example: Reducing unnecessary re-hospitalizations will drive much of the

decision making. Ensure delivery system transformation continues beyond the

waiver period through leveraging managed care payment reform.

Key theme is collaboration!

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www.health.ny.gov/health_care/medicaid/redesign/mrt_1458.htm

TRANSITION OF NURSING HOME POPULATIONS AND BENEFITSTO MEDICAID MANAGED CAREFrequently Asked Questions Document(three sets dated Jan., March and June 2015)

Transition of Nursing Home Populations and Benefits into Medicaid Managed Care Recorded Webinar and Slides (July 2015)

Consumers, family members and representative have the right to file a complaint with any of the following:

• MMC Complaint line 800-206-8125 • MLTC Complaint line 866-712-7197

Official Resources

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Critical Issues for Discussion:

In or Out of Network – Impact on Admissions.

Medicaid Eligibility and Pending

Changing Enrollment.

Working with plans assigned care or case worker.

Pre-Authorizations and Authorizations.

Plan assessments, care planning, quality assurance and satisfaction surveys.

Define your process of insurance verification and dis-enrollment from plan.

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Critical Issues for Discussion:

Provider and plan disagree? Conflict –Free Evaluation process

Fair Hearing Rights.

Know your contracts and billing manuals.

Cash Flow Impact.

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True or False?

Nursing homes will no longer be eligible for bed hold payments under Medicaid managed care

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MC Transition Quiz

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Reimbursement Update – Transition to MC

FALSE

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True or False?

Even for non-emergency services at an out-of-network hospital, prior authorization from the Medicaid MCO is not needed

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MC Transition Quiz

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FALSE


True or False:

All 70 counties in the state now require mandatory managed care enrollment for new permanent nursing home residents whose care is covered by Medicaid

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MC Transition Quiz

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There are only 62 counties in New York (but all of them do require mandatory MMC enrollment for nursing home residents)

FALSE

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True or False?

An individual in need of permanent nursing home care seeking Medicaid eligibility who is NOT enrolled in managed care will be required to enroll into a managed care plan prior to Medicaid eligibility determination.

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MC Transition Quiz

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FALSE

True or False?

Lock-in provisions do not apply to nursing home residents enrolled in a managed long term care plan meaning they can change plans mid-year.

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MC Transition Quiz

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TRUE !

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MC Transition Quiz

True or False? This timeline is for a current MMC plan enrollee.

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MC Transition Quiz

This timeline is for an individual NOT yet enrolled in managed care. FALSE

True or False?

If an MCO and nursing home are relying on the benchmark rate, barring an alternate contractual arrangement the plan must pay the home retroactive case mix updates.

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MC Transition Quiz

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TRUE !

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Patrick Cucinelli

[email protected]

518-867-8383, ext. 145

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Thank You!

Social Work Over the Rainbow ... - LeadingAge New York Work...11/9/2015 1 Social Work Over the Rainbow Elliott Frost Leading Age NY Discussion Points Proposed new CMS regulations Survey

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