Coalition for Compassionate Care of California (CCCC)

Transcription

1 PALLIATIVE CARE FOR HEALTH HOME PROGRAM PATIENTS IN CALIFORNIA Leah Morris, RN, MPH, NP Director of Policy and Payer Relations Coalition for Compassionate Care of California. Lael Duncan, MD Medical Director Coalition for Compassionate Care of California Coalition for Compassionate Care of California (CCCC) CCCC works broadly to achieve the best possible care for those with serious illness or facing end of life, to ensure they get the care they need and no less, the care they want and no more. In partnership with thought-leaders from healthcare systems, provider groups, government agencies, consumer organizations, and the general public, we provide advocacy, education and resources to expand palliative care across the continuum of care.

2 Today s Objectives Define and describe palliative care as it applies to the implementation of the Health Home Program (HHP) in California Understand how SB 1004, Medi-Cal Palliative Care, relates to the HHP List the usual elements of a palliative care program in the primary care or HHP setting Implement screening for palliative care needs into development of the HHP Health Action Plan (HAP) Discuss how creating palliative care programs and capacity in the primary care setting can address the needs of HHP patients Health Home Program for Patients with Complex Needs (Health Home Program,or HHP) The HHP is designed as an intensive set of services for Medi-Cal Managed Care Enrollees with chronic conditions who require care coordination at the highest level. The HHP includes requirements to address the unique needs of members experiencing homelessness.

3 Health Home Program Policy Goals Improve care coordination Integrate palliative care into primary care Strengthen community linkages within health homes Strengthen team-based care, including use of community health workers/ promotores /other frontline workers Improve health outcomes of people with highrisk chronic conditions Report net cost avoidance within two years DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL DHCS HHP Additional Focus Areas Focus on High-Cost Medi-Cal Members with Chronic Conditions Wrap Increased Care Coordination Around Existing Care The MAIN GOAL of the HHP is Comprehensive Care Management

4 ROLE of the Community-Based Care Management Entities (CB-CMEs) CB-CMEs serve as the frontline provider of HHP services and are rooted in the community In conjunction with the Managed Care Plan (MCP), ensure assigned HHP member receives access to HHP services In many cases, CB-CME is a primary care provider DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL Palliative Care Integration into Primary Care for HHP Members Integration of palliative care into primary care delivery is a defined Guiding Principle and Policy Goal of the Health Home Program DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL

5 What is Palliative Care? California Health Care Foundation defines Palliative Care this way: Palliative care is a recognized medical specialty as well as a philosophy and approach to care. Rooted in an interdisciplinary model of care, palliative care offers relief from suffering for patients with serious and complex illness, and addresses and promotes patient and family quality of life.provided at any age or stage of illness along with curative treatment. emphasis added Weaving Palliative Care into Primary Care: A Guide for Community Health Centers CHCF.org Palliative Care Services for HHP members: SB 1004 Medi-Cal enrollees eligible for the Health Home Program may also be eligible for palliative care. Recent California legislation (SB 1004) directed establishment of standards for Medi-Cal managed care plans to ensure delivery of palliative care services. On September 8, 2016, the State released a policy paper describing expectations for palliative care for Medi-Cal enrollees. DHCS SB1004 Medi-Cal Palliative Care Policy, Sept Update

6 Department of Health Care Services HHP members may be anywhere along this continuum. HHP Members may be appropriate for: Early Palliative Care SB 1004 Palliative Care Hospice Care DHCS SB1004 Medi-Cal Palliative Care Policy, Sept Update

7 Early Palliative Care Services Primary/Early Palliative Care: Psychosocial and spiritual support for a diagnosis of a serious illness Assistance with Family Medical Leave, disability applications etc. Education and support for family members Symptom management during treatment Introduction of advance care planning (ACP) and identification of surrogate decision maker DHCS SB1004 Medi-Cal Palliative Care Policy, Sept Update SB 1004 Palliative Care SB 1004 Palliative Care (in part) includes: Psychosocial and spiritual coping with disease progression Assistance applying for disability, financial planning, insurance, etc. Education and support for family members Discussion of benefits/burdens of treatments options and goals of care Symptom management during treatment Focused advance care planning and selection of durable power of attorney for healthcare DHCS SB1004 Medi-Cal Palliative Care Policy, Sept Update

8 HHP members may be anywhere along this continuum. HHP Members may be appropriate for: Early Palliative Care SB 1004 Palliative Care Hospice Care DHCS SB1004 Medi-Cal Palliative Care Policy, Sept Update Health Homes Program Services HHP Services Comprehensive Care Management * Care Coordination Health Promotion Comprehensive Transitional Care Individual and Family Support Services Referral to Community and Social Supports Philosophically an Element of Palliative Care? YES YES YES YES YES YES DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL

9 Early Palliative Care Essential Elements: Perspective from California Health Care Foundation Care management and coordination for patientcentered, quality-of-life focused care delivered by an interdisciplinary team with: Systems for routine assessments of symptoms and care needs Pathways for triage and referral to address changing patient needs Communication with families Advance care planning Weaving Palliative Care into Primary Care: A Guide for Community Health Centers CHCF.org Eligibility for Palliative Care Services Any Medi-Cal HHP member is appropriate for Early Palliative Care and should be engaged in advance care planning For SB 1004 Palliative Care (more advanced specialty palliative care) additional specific criteria exist for determining eligibility-- as they do for HHP members Screening for palliative care needs and other HHP service needs can occur simultaneously

10 SB 1004 Palliative Care Eligibility Eligibility for SB 1004 Palliative Care includes more detailed clinical information, such as: Diagnosis of Cancer, CHF, COPD or Liver Disease Repeated use of hospital Emergency Departments or hospitalizations for the disease The patient s death in a year would not be a surprise This is specialty service for patients with advanced illness. The HHP and primary care providers are not expected to offer SB 1004 Palliative Care. MCPs are in the midst of developing appropriate referral resources for SB 1004 Palliative Care Integrating Palliative Care into Primary Care CB-CMEs, as the provider of services for HHP members, will be responsible for some level of integration of palliative care for HHP member patients. What does this mean for CB-CMEs?

11 HHP and Early Palliative Care Focus on patients with serious illness or medical complexity Care is team based Patient participation & engagement are central SCREEN, ASSESS AND MANAGE CARE Screening All HHP members will have a Health Action Plan (HAP): The comprehensive, individualized, person-centered care plan that incorporates physical health, mental health palliative care social supports HHP members, along with their family/support persons, are encouraged to collaborate with the Care Coordination and Care Management to develop this HAP DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL

12 Assess HPP Health Risk Assessment will help identify members who need Early palliative care (support with early diagnosis, early assistance with FMLA, introduce ACP for those who do not have plans etc.) The HAP should include documentation of an assessment of needs for Early palliative care Manage Once needs are identified, develop the HAP to address and begin action steps toward accomplishing care needed, including providing Early palliative care Identification of needs for more specialized palliative care ( SB 1004 Palliative Care ) may arise. Note such HHP member needs on the plan HAP and work with the MCP to make appropriate referrals.

13 Notes on palliative care for HHP members All CB-CMEs will need to understand and offer or refer for Early palliative care. Some CB-CMEs will need to develop skills to provide Early palliative care (such as how to begin ACP) Some CB-CMEs have mature palliative care skills for both Early and SB 1004 Palliative Care MCPs are developing policies and plans to meet HHP and SB 1004 Palliative Care requirements Key Points: Palliative care in primary care Include assessment for palliative care needs into the development of the Health Home Program member Health Action Plan (HAP)* Provide all HHP members with access to advanced care planning* *DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL

14 Putting Palliative Care into Action: CB-CMEs Evaluate your practice/setting & resources for Early palliative care readiness Plan your program Choose your tools (screening, patient engagement, monitoring ) Train your staff Metrics look to DHCS and MCPs for further guidance Ask for help if needed! Thank you! Questions?

15 Training your staff: Resources Coalition for Compassionate Care of CA or In person and online training in advance care planning, end-of-life care communication, culturally competent approach to care, issues in palliative care, skills training, consulting. CSU Palliative Care Institute Web-based training for palliative care and advance care planning CAPC The Center to Advance Palliative Care Resources for palliative care program development. Presentation resources DHCS Health Homes for Patients with Complex Needs: California Concept Paper FINAL Department of Health Care Services SB 1004 Medi-Cal Palliative Care Policy September 1, 2016 Update aspx Weaving Palliative Care into Primary Care: A Guide for Community Health Centers CHCF.org California Health Care Foundation