*This article originally appeared on the Open Minds website.
Last year we really began tracking the Medicaid long-term services and supports (LTSS) move to manage care models, and the industry shift of services for consumers with intellectual/developmental disabilities (I/DD) in that direction as well. As we’ve reported before, 50% of consumers with I/DD receive their health and behavioral health benefits through Medicaid health plans—and 15% of those consumers have their LTSS services delivered via managed care models (see I/DD & Managed Care? There Will Be Requirements). One of the developing trends in primary care is the use of the Patient-Centered Medical Home (PCMH) is a care delivery model that coordinates these consumer services through primary care.
For more this month on those solutions, we reached out to Tine Hansen-Turton, President and Chief Executive Officer at Woods Services, Inc. Woods is a population health management nonprofit organization that supports children and adults with developmental disabilities, complex medical needs, behavioral and other challenges to achieve their highest potential and independence through innovative and individualized approaches that promote learning and personal fulfillment. Woods offers integrated health, education, housing, workforce, behavioral health services, and case management services.
Last year Woods opened an expanded medical center, featuring a patient-centered medical home (PCMH) program for Keystone First members with intellectual and developmental disabilities (I/DD) and complex medical challenges. Woods provides integrated high-quality primary and preventive care along with behavioral health care for patients through expanded medical center hours, adding new primary care providers, increasing access to medical services such as radiology and lab services, and technology that will enable improved coordination and continuity of care, leading to better health outcomes for people with I/DD. The Medical Center, to date, has been not only a great success in itself but has excited tremendous interest among providers and government funders as a positive way forward in meeting the complex medical needs of the I/DD population.
The services provided by Woods are intended for people with I/DD, brain injury, or involved with the child welfare system and who, in many cases, also have complex and intensive medical and behavioral health care needs. Woods offers 200+ health and human service programs from locations in Pennsylvania and New Jersey to 18,000+ children, adolescents, and adults, with referrals from 175 school districts and 23 States. Woods’ annual gross revenue is approximately $320 million. Ms. Hansen-Turton noted:
When I entered the field three years ago, what intrigued me is how people like me could have worked in the human services and health care sectors so long and missed the fundamental fact that 7% of the population, accounting for a third of our government costs through Medicaid and Medicare, are developmentally disabled. The reality is when you serve this highly vulnerable population, they are going to need lifelong supports. That requires a very different lens on how you deal with this population. These consumers are going to need strong relationships with health care teams their whole lives. That takes integrated primary health care. We also must look at people’s homes and environment (the social determinants of health). With the right wrap-around model with this population (care coordination, integrated primary care and behavioral health and medication management), I think we could decrease costs by 20% or 25% and free up more money for more community supports. It’s just that, from the medical perspective, it’s been a hidden group.
Keystone First is a Medicaid managed care plan, an affiliate of Independence Blue Cross, in five southeastern Pennsylvania counties (see Woods Services Opens I/DD-Focused Patient-Centered Medical Home For Keystone First Members). Ms. Hansen-Turton noted:
It’s a pilot with Keystone’s Medicaid managed care plan. I went to them and said we have a population that the health care system has completely ignored. They are high utilizers of emergency rooms and have higher than normal hospitalization rates. We worked on a plan and brought in 150 consumers as part of the Keystone First model. Our model is to provide enhanced quality primary health care at the Woods Health Center and keep clients from using emergency rooms unless it is a real emergency. We are also collecting quality data and HEDIS measures.
Additionally, last month New Jersey granted Legacy Treatment Services of Hainesport, New Jersey the approval to formally affiliate with Woods to expand Woods’ comprehensive, coordinated approach to care for consumers with complex medical and behavioral health care needs due to a wide range of intellectual and developmental disabilities, genetic disorders, child welfare issues, and brain trauma (see Woods Services & Legacy Treatment Services Affiliate To Transform Clinical Care In New Jersey & Pennsylvania). Ms. Hansen-Turton explained the timeline:
Legacy is primarily a behavioral health care organization. Together, we are planning to open up a second specialized patient-centered medical home in New Jersey in 2020.
The majority of The Woods consumers are on Medicaid and their programs are reimbursed through fee for service. However, to demonstrate the cost savings and value of the partnership with Medicaid managed care organization Keystone, Woods was able to secure a wraparound funding rate that mirrors more closely that of a community health center.
The Woods care teams consist of primary care providers, nurse practitioners, family physicians, pediatricians, neurologists, an optometrist, podiatrist, radiologist, psychiatrists, dentists, dental technicians, nurses, and medication techs. Ms. Hansen-Turton explained:
We are retelling the story of what needs people with IDD have, and we’re being intentional about the missing piece which is access to quality health care along with access to providers who have been trained to take care of this specialized population. We’re looking at our team now and evaluating what the future care system for the IDD community will need to look like in a managed care environment. We are retraining our nurses to be nurse navigators to work along-side social workers and our medical, education and residential programs team. The team in the future needs to be a “whole care team” working together to think holistically about what consumers with IDD need along their continuum of care throughout the lifespan. The care plan can drive a lot of the services, but it has to be integrated with primary care, behavioral health and medication needs.
In terms of performance, Ms. Hansen-Turton stressed the importance of the Healthcare Effectiveness Data and Information Set (HEDIS) to Keystone, and other managed care companies (MCO). She explained:
Keystone’s perspective was, as with all managed care plans, they need better HEDIS scores for the IDD population. Working with Woods will make them look good on that scoring and we already have. I believe we are going to do a lot better because we are population health focused. It’s about access to data, managing a complex population with quality accessible, affordable care, and saving the system money. Our plan, once the model is fine-tuned, is to open it up to the wider community to serve families with loved ones and people with I/DD who are struggling with access to primary care.
While we have an enhanced rate, our hope is to certainly move to value-based reimbursement, and this is all the beginning of the legwork to becoming value- based.
Ms. Hansen-Turton expressed the optimism that Woods will learn a lot when they look back at their pilot data, with the hopes of expanding this model to other places—with an eye on “critical mass” for working with consumers in this community. She noted:
The idea is that it will pay for itself. The margins are lower in primary care, but with the right funding model it should pay for itself, save Medicaid and Medicare funds, and enhance quality of care. Now, our sector needs an investment in our data systems. Someone needs to look at building a system that’s completely integrated with health care. I very much see our sector becoming an integrated part of the health system where all of the services are connected.