SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions (California Department of Health Care Services) February 24, 2012 Los Angeles County 3800 Kilroy Airport Way Suite 100 Long Beach, CA 90806 V1VIAQ --.-- VwA4llw-~2njLv:-r-wuznm..2 2.*--#7i *121**13 1.1' 1a-F . ll? 1.-.-1-11.11;-.--1:131;.fhgIlizg?xkl ITCI gi I YI-L11'jtf 11'lL1-1 1.-11-2..211-*11 -2--1111 -1111,11*313911..1-. 2% :gY`g` I I y111_.-Z. - 1- -.1II Jin. 1, .1 1.-. - - - -- 1--1- -- .. -11. -- -.-.111 1 . -- .--.- . - - -- .1-any-1,.-11. It- 1. -111_1..y-gc. .. . .-.1 . xl. .- v_ .--. 1--. .1 I 1 1V 1 . 1r1{crt -EUR1..- G-V: -431-- rr: -1-- i- -..111-1,; 191:* 1_ .1 11-1.1. Q-.- .--ruL T-1iuda.- "r7 . Ill41IFIQI MInjwi-z?r?? VV}3rfail - L-.- . `-wwejtmxeb ipa11uhn`-- --ImiItug?ir. - - :117- ?`.L_u - rc- t?.I.-Mh..I';Qu. 1.wigJn. ~qv(frrar..: gz,i,-rV__ - . -. I I W?g'ri5-if .- I . ?o ,q.IQI ITL LITE . . 4-.. II--`fiy,?-.1*li.07Eliuh3.:21y- . I I . 1. .IwcEURI .;nur`;. ..-. {Mw ;rmnf.: .9 4 A . .. I I . QL t` sig" I -- 3 hr..-- . .-1- ..-.-- .- . . . lIyi; ;vy.,L1.-: .. . - - .. a-J? I -- --.- -. - V-M Vzj?II?vV~gI_fi.--. I . . qi`- I I I?42?izaI5_I;r I I I I I I2I--.- --..-. JlEUR`vyww.? 1 - I I Iqugl- _I_i . xp.-.. . - - -. Ir NQSK .I {ey.-iif . f-@12. . A ;lSFII.-I. I ir`yva . . . - . ., '..1., .,ileExecutive Summary The Applicant must provide a two-page executive summary of the Demonstrati on project. This shoul d serve as a succinc t description of t he proposed project, including the goals of the project, the proposed geographic coverage area, number of projected dual eligibles to be enrolled, and list of strategic partnerships that will be developed to carry out the project. Wr ite the executive summary so th at it is clear, accurate, concise, and without reference to other parts of the Application. SCAN Health Plan (SCAN) co mmends the State of California's proposal to enroll all Californians who are dually elig ible for Medicare and Medi-Cal ("dual eligibles" or "duals") in high-quality, integrated health plans, beginning in 2013. Dual eligible patients deserve seam less access to the car e and social supports and services that will help them maintain good health and a high quality of life in the setting of their choice. SCAN has provi centered care to dual eligibles since ded high-quali ty, integrated, personshortly after our founding by comm unity activists nearly 35 years ago. SCAN has extensive experience in coordinati ng Medicare, Medicaid, and hom e- and co mmunity-based services (HCBS ) benefits, as well as supplem ental services, maki ng SCAN one of onl y a few health plans nationwide capable of executing on the Stat e's integrated care model i mmediately. Today, SCAN is the nation's fourt h la rgest not-for-profit Medicare Advantage plan, serving nearly 130,000 individual s, and is the only fully-integrated dual eligible special needs plan (FIDE SNP) in California. Throughout t hat significant expansion, SCAN's m ission has stayed a nd will remain the sam e: the pursuit of SCAN Health Plan 1 innovative ways to enhance o ur m embers' ability to m anage their health and control where and how they live. Through California's Dual Eligib le Demonstration (the "Dual s Demonstration"), SCAN proposes to tran sition duals from the current disjointed fee-for-service system to a fully integrat ed system of care delivery under SCAN's person-centered Model of Care. In doing so, we will im prove health outcom es, increase the quality of and members' satisfaction with care, and optimize the use of Federal and State resources, all while maximizing our members' ability to continue living in the community. SCAN's Model of Care has already proven successful for our enrolled duals, in terms of quality of care, outcomes, and costs. For example: o Ninety-eight (98) percent of SCAN's nursing facility level of care (NFLOC) duals in California are able to reside in the co mmunity instead of in longterm care institutions. o A recent study revealed that SCAN's HEDIS 30-day All-Cause Readmission Rate for dual eligible m embers in 2010 wa s 23 percent lower than that of a similar cohort of fee-for-service enrolle d duals in C alifornia, and 24 percent lower than expected based on enrollees' average adjusted probability. o In 2011, 97 percent of SCAN dual eligib le members said they were satisfied with SCAN, and 94 percent said that SCAN helped them live independently. SCAN Health Plan 2 SCAN proposes to expand our dual eligible enrollment to serve an additional 36,000 duals throughout Los Angeles C ounty. SCAN will provide seam less access to the full array of Medicare, Medi-Cal and LTSS benefits, as well as a range of important supplemental benefits, such as dental care and transport ation, in a culturally sensitive and clini cally appropriate manner. We will structure financial incentives to encourage medical providers to meet quality benchmarks. In addition, we will enhance our already robust partne rships in the local comm unity, including with the Departments of Mental Health Guardian, HCBS providers such as Co and Public Soc ial Services, Public mmunity-Based Adult Services (CBAS) centers, and community resources such as Meals on Wheels and independent living centers. SCAN is deeply invested in the goals of the Duals Dem onstration. We are ready and willing to help the State and CMS integrate care and im prove overall health outcomes while promoting individuals' independence a nd control over how that care is delivered. SCAN Health Plan 3 Section 1: Program Design Section 1.1: Program Vision and Goals Question 1.1.1: Describe the experience serving du ally eligible beneficiaries, both under Medi-Cal and through Medicare Advantage Special Needs Plan contracts, if any. SCAN Health Plan (SCAN) has a long hi story of serving dually eligi ble, dually enrolled beneficiaries and com bining Federal and Stat e fundi ng to delive r comprehensive, coordinated, person-centered care. SCAN was founded in 1977 by a group of seniors who were frustrated by their lack of acces s to services and wh o sought an organization that addressed their specific need s. These forward-thinking individuals formed the Senior Care Acti on Network, now known as SCAN Health Plan. SCAN's goal then was the same as it is today: to find innovative ways to promote our m embers' ability to m anage their health and control where and how they live. In pursuit of this m ission, SCAN was an original participant in California's Multi-Purpose Senior Services Program (MSSP). Today SCAN operates the largest MSSP sit e in the State through SCAN's (HCBS) division, Independence at Home(TM) home and comm unity-based services (IAH). SCAN also participated for more than two decades in Medicare's So cial HM O Demon stration, incorporating HCBS benefits into a comprehensive a ssessment and care management program. Since 1985, SCAN has used SCAN Health Plan Medicare and Medi-Cal funding to provide a fully 4 integrated array of Medicare, Medi-Cal, and HCBS benefits to dual ly eligible enrollees under contracts with Medicare and Medi-Cal. Under the Social HMO Demonstratio n, SCAN managed a population that met nursing facility level of care (NFLOC) criteria. Case managers conducted comprehensive assessments in the home to qualify the beneficiary for participation, to ascertain the level of im pairment, a nd to identify which co mmunity resources could suc cessfully address these de homemaking (including m ficits. SCAN provi ded personal care, eal preparati on and m aintaining sanitary living conditions), hom e-delivered meals, nutritio nal supplies, inc ontinence supplies, a telephone emergency response system, adult day c are services, bath equipm ent, and lim ited inpatient respite. SCAN's current care m anagement m odel evolved from our experien ce as a Social HM O. It emphasi zes prevention and ear ly intervention, spans the continuum of a beneficiary's health status, and provides t he right care at the right time. Our early experience in m anaging frail, NFLOC case management beneficiaries has directly informed th e design of our current services, our i nvestment in training a highl y com petent field staff, and our dedication to buildi ng deep relationshi ps with c ommunity agencies. Since 1985, SCAN Health Plan 5 SCAN's program of specialized services is estimated to have delayed or prevented 100,000 nursing home admissions in California. 1 As the Social HMO dem onstration e nded, SCAN became a Special Needs Plan (SNP) when that program was create d as an offering i n Medicare Advantage. Today, as the nation's fourth l argest not -for-profit Medicare Advantage plan and the only CMS-approved Full y-Integrated Dual Eligible SNP in California, SCAN provides com prehensive, coordinated car e to nearly 130,000 individuals in Medicare Advantage, including approximately 8,000 dually enrolled dual eligibles in California. SCAN has served dual eligibles in dual eligible Special Needs Plans (D-SNPs) since 2006. In addition, dual eligibles make up about 85 percent of SCAN's chronic condit ion Special Need s Plan (C-SNP) enrollment. SCAN maintains a contract with the State of California for D-SNPs in L os Angeles, Riverside, and San Bernardi no Counties. Although we do not have a contract with the State for San Joaquin County, SCAN nevertheless provides care coordinati on services to dual eligible mem bers residi ng t here. SCAN has also served as a contractor for the Arizona Long Term Care System (ALTCS) since 2006, enrolling both disabled and ol der adults who are low-income, meet NF LOC criteria, and suffer from physical, functiona l, or behavioral impair ments. In Arizona, SCAN 1 Internal calculation based on the number of NFLOC-qualified enrollees since 1985 who have remained in their homes instead of residing in an institutional setting. 6 SCAN Health Plan deploys 50 case managers to provi de ca re management, comprehensive medical care, and supporti ve in-hom e services to a mem bership of 2,700. Across all of SCAN's product lines, including MSSP and our Arizona plans, we currently serve approximately 12,000 duals. SCAN has an extensive and successful track reco rd serving dual eligibles with complex health needs, both elderl y and non-elderly. SCAN 's dual eligibles assessed at NFLOC have, on average, three to four severe chronic condi tions and take m ore than four prescription m edications. More than 70 percent have hypertension and nearly 40 percent are ove rweight, putti ng t hem at high ri sk for diabetic and cardiovascular condit ions. Indeed, m ore than one-thi rd of SCAN beneficiaries have diabetes, and another quarter have vasc ular disease. Despite the complexity of this population, however, re cent analyses of SCAN's dual eligibles reveal that SCAN successfully keep s NFLOC memb ers in the community, improves health and reduces ut ilization of expensive services such as inpatient and skilled nursing facility (SNF) st ays, and performs very well on a range of process, outcomes, and quality measures. For example: o Ninety-eight (98) percent of SCAN's NFLOC dual eligibles in California are able to reside in the commun institutions. 2 ity instead of in long-term care 2 Internal reports by SCAN Health Plan. SCAN Health Plan 7 o Within the first six m onths after enrollment in our Geriatric Heal th Management program , the percentage of m embers with an inpatient admission was reduced by 45.6 percen t and the percentage o f memb ers who had an emergency room visit was reduced by 22.7 percent.3 o Participating in SCAN's Conges tive Heart Failure (CHF) Disease Management program reduced inpatie nt bed days by 25.4 percent and SNF bed days by 39 percent as co mpared with members who were not enrolled in the program (adjusting for medical group variation). 4 o In 2011, 97 percent of SCAN dual el satisfied with SCAN and responded th igible mem bers said they were at SCAN helped manage their health, and 94 percent said that SCAN helped them live independently. 5 o A recent study conducted by Avaler e Health comparing HEDIS 30-day All-Cause Read mission Rates betwee n dual eligibles enrolled in SCAN Health Plan versus Medicare FFS du al eligibles found that SCAN's dual eligibles had a read mission rate that was 23 percent lower than a sim ilar 3 Ibid. 4 Ibid. 5 Ibid. SCAN Health Plan 8 cohort of California FFS dual eligible beneficiaries (15 percent and 19. 5 percent respectively). 6 o The Avalere Health study also found t hat SCAN Health Plan scored better than Medicare FFS on ARHQ's Prevention Quality Indicators (PQI) Overall Composite, dem onstrating a 15 percent lower inpatient admission rate for conditi ons that compose the co mposite measu re, including COPD, CHF, and bacterial pneumonia. 7 o In 2011, SCAN perform ed in the 90 th percentile am ong Medicare D- SNPs on a wide range of quality m easures, including colorectal cancer screenings, glauco ma screenings, and on a num ber of comprehensive diabetes care measures. o A 2010 study by the University of Sout hern California found that if a beneficiary adm itted to a skilled nursing facility re ceived SCAN HCBS 6 The Avalere Health study compared outcomes on the AHRQ Prevention Quality Indicators (PQI) Overall Composite and the HEDIS 30-day All-Cause Readmission Rate between Medicare FFS dual eligibles in California and dual eligibles enrolled in SCAN Health plan. The PQI Overall Composite measures potentially avoidable hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs), which are intended to reflect issues of access to, and quality of, ambulatory care in a given geographic area. The analysis was conducted on a sample of SCAN Health Plan duals enrolled in SCAN's Medi-Medi plan for at least one month in 2010, but were continuously enrolled in SCAN Health Plan for all of 2009 and 2010. Similarly, Medicare FFS duals were identified as beneficiaries who were enrolled in Medi-Cal for at least one month in 2010. (See data table at Appendix 9.) 7 Ibid. SCAN Health Plan 9 and case management services, there was a 26 per cent greater likelihood of discharge to a home setting as co mpared with FFS beneficiaries who did not receive thes e services , help ing to m inimize conversions from short term to long term institutional stays.8 In addition, SCAN maintains a 4-star overall quality rating based on a range of process, access, and outcome m easures under the Medicare Advantage quality rating program. This high performance rating earns SCAN qu ality bonus payments from CMS. In sum , our experience and history of high performance in caring for the dual eligible population make SCAN one of only a very few plans nationwide that have the expertise and capability to deli ver com prehensive, person-centered care under the Duals Demonstration. Question 1.1.2: Explain why this program is a st rategic match for the Applicant's overall mission. The California Dual Eligible Dem onstration and SCAN share a co mmon mission: to provide high-quali ty, coordi nated, con tinuous, self-directed care that enables at-risk patients t o li ve where a nd how t hey choose. For nearly 35 years, SCAN has developed innovativ e ways to help individuals manage their health and 8 Thomas K, Gassoumis Z, and Wilber K. (2010) Conversion diversion: Participation in a social HMO reduces the likelihood of converting from shortstay to long stay nursing facility placement. Journal of the American Medical Directors Association, 11, 333-337. 10 SCAN Health Plan maintain their independence. We are pleased that the State of California is leading the movement to make integrated care the standard for dual eligibles. No group is more deserving of the wrap-around servic es and integrated health care envisi oned by the State's Demonstration. That is why SCAN, in its health plan model and as a home and comm unity-based care management organization, sees the Duals Demonstration as a trem endous opportunity to fulfill our mission. On the broadest scale to date, we will be able to pr ovide culturally and econom ically diverse seniors and disabled adults with patient-centered hea lth care and HCBS that will allow them to maintain their independence and to lead healthy lives in their homes. SCAN is committed to working with bot h the Federal government and the State of California in this important endeavor to in tegrate all health care services for duals in a logical, co mprehensive manner that improves the quality and lowers the cost of health care. This co mmitment, our m ission, and our experience make S CAN uniquely suited to participate in the Duals Demonstration. Question 1.1.3 : Explain how the program meets the goals of Demonstration. the Duals a. Coordinating benefit s and access to care, im proving continui ty of care and services. SCAN maintains a coordinated care mana gement m odel that is disti nctly designed for the dual eligible population, who, in addition to having low incomes, may also be frail and disable SCAN Health Plan d, and are likely to suffer from com plex chroni c 11 conditions. Upon a mem ber's enrollment, SCAN engages in individual assessm ent to determ ine the mem ber's overall need s, followed by care coordination for all dual eligible memb ers, and targeted care management services for those wit h chronic conditi ons and/or i dentified ps ychosocial needs. SCAN has a dedicated team that works to achieve continuity of care, regar dless of payer (e.g., a memb er receiving skilled nursing facility services who exhausts the Me dicare benefit and continues receiving care under the Medi-Cal b enefit). To ensure continuity of nonmedical services, SCAN's specially-trained staff link memb ers to the services an d supports t hey need and m onitor their use. In addition, dual eligible mem bers can always contact a member of the Personal Assistance Line (PAL) Unit for live, oneon-one telephonic assistance with underst anding and accessing all the benefits to which they are entitled. Thus, throu gh our person-centered approach, SCAN supports dual eligible members in a comprehensive way, providing m embers with the information, support, and assistance necessary to activel y m anage their own care. b. Maximizing the ability of dual eligib les to remain in the ir hom es and communities with appropriate services an d supports in lieu of institutional care; and Increasing availability and access to home-and co mmunity-based alternatives. SCAN has m ore than 30 years of expe rience in coordinati ng HCBS for our members. Our experience has proven that memb ers who receive the appropriate HCBS stay healthier and able to remain SCAN Health Plan in the community, rather than requiring 12 institutional care. As a result, we provide HCBS benefits not only for our own plan members, but also for other plans' mem bers and for FFS beneficiaries through our IAH division. Under the Dem onstration, SCAN will leverage and build upon our existing partnerships with co mmunity hea lth care and service organizations to improve our new mem bers' access to HCBS relative to FFS. Our links to these organizations are strong and will be further enhanced under the Duals Demonstration. For exam ple, we have co llaborated with ot her non-profits i n the community to host events benefiting sensitive populations, participated in fundraising activities, and conducted cross-training of our staffs to work together more effectively. Under the Dem onstration, we will work with agencies including ADHC/CBAS centers, Meals on Wheels, I ndependent Living Centers, Disability Rights Centers, car egiver ag encies, senior centers that offer chronic diseas support services, and housing provider s--many of which are already strong e partners of SCAN. Through ou r ongoing partnerships, these agencies also have the benefit of maintaining their client base and their ability to continue providing services even when fluctuations in the economy or State funding occur. c. Preserve and enhance the ability for co nsumers to self-direct their care and receive high quality care. At SCAN, a patien t's choice is fi rmly respected . Whether it involves primary care physicians (PCPs), medical gr oups, social workers, care navigators, or telephonic assistants, our patients have the right to SCAN Health Plan choose care that satisfies 13 them. The patient is at the center of th needs and preferences drive the flow of e SCAN Model of Care. Indeed, patient care. Every dual elig ible pla n mem ber participates in the de velopment of an In dividualized Care Plan based on identified needs and the member's input on the Hea lth Risk Assessment (HRA). If a mem ber has identified needs, a SCAN case manage r will contact the mem ber by phone to collaboratively develop his or her care plan . The memb er's finalized care plan is documented in SCAN's softw are platform, the McKesson CareEnhanced Clinical Management System (CCMS), and mailed to the mem ber along with inform ation about who to call for help in m anaging his or her conditions or to discuss changes in his or her health status. Memb ers are en couraged to review their care plan with their physician. Specifically for dual e ligible members meeting NFLOC criteria, a SCAN field specialist meets face-to-face or by phone with the SCAN RN and the member and his or her caregiv er to develop a care plan. The care plan includes an HCBS plan, identifying additional services that would assist the memb er, such as personal care services and Meals on Wheels. The mem ber is given a copy of the care plan and another copy is mailed to the PCP. Through these processes, dual eligible members actively direct their ca re and SCAN ensures that they receive high quality care to meet their individual needs. d. Improve health processes and satisfaction with care. SCAN Health Plan 14 SCAN is co mmitted to continually im proving the quality of care our members receive. For 2012, SCAN's Medi care Advantage plans received a CMS rating of 4 stars overall, including high ma rks on process measures and beneficiary satisfaction. In particular, SCAN signi performance on HEDIS measures of co screening, and colorectal can receiving the right care at th ficantly exceeded the national average mprehensive diabetes care, glauco ma cer scr eening. To ensure that our memb ers are e right time , and t hat they have high levels of satisfaction with the car e they receive from our contracted providers, SCAN engages in ongoi ng evaluatio n and m onitoring (see Sec tion 8). At the time of contracting, SCAN conducts a Medical Mana gement Infrastructure Assessment of our provider groups to ident ify any ga ps in care processes and t o develop and implement action plans to bring all provid ers into alignment with best practices. SCAN tracks the results of our oversight and m onitoring activities in our Quality Committee Structure. We also routinely su rvey mem bers and their caregivers, as well as providers, to identify any gaps in adjustments to remedy them. e. Improve coordination of and timely access to care. SCAN aims to deliver the right care at the right tim e to our m embers. care, quality or access, and we make Through SCAN's indivi dualized care management m odel, our care coordi nators ensure that members are accessing the services they need in a t imely way, ranging SCAN Health Plan 15 from preventive services for healthier me mbers, to ongoi ng case m anagement for members with more co mplex needs, to care transition services for member discharged from acute or post-acute ca re facilities. We share tim s ely patient information with providers to e nsure efficient utilization and c oordination among medical services, as well as track mem services. f. Optimize the use of Medicare, Medi-Cal and other State/County resources. By integrating m edical care and non- medical supports and services under a single umbrella, SCAN will optim ize the us e of all the benefits for which dual eligibles qualify, along with additional co mmunity-based services that will allow them to remain independent. The current FFS system , financed through Federal, State, and local sources of funding, is disjointed and inefficient. This often leads to beneficiary confusion and frustration, with many forgoing care that can prevent the need for more intensive service use lat er. Additionally, the current system fosters the perverse incentive to avoid providing Medicaid-paid services that can actually prevent the need for more intensive use of Medicare-covered services. Under the Duals Dem onstration, SCAN will con tinue our current holistic approach to bers' use of non-medical supports a nd assessing needs and delivering care that op timizes resources and im proves quality and the mem bers' experience. Using our efficient systems of care delivery and SCAN Health Plan 16 coordination, SCAN is confident we can reduce cost under the Duals Demonstration as compared to the current bifurcated FFS system. Section 1.2: Comprehensive Program Description Question 1.2.1 : Describe the overall design of the proposed program, including the number of enrollees, proposed partne rs, geographic coverage area and how you will provide the integrate d benefit package described above along with any supplemental benefits you intend to of fer. (You may mention items briefly here and reference later sections where you provide more detailed descriptions.) Under the Duals Dem onstration, SCAN will apply our tim e-tested, team based care m anagement m odel to transit ion duals from Medicare and Medi-Cal FFS in a way that improves health outcomes, increases quality of care, and reduces overall costs. SCAN's m odel will addre ss the needs of dual eligibles in a , co mbining culturally sensitive and comprehensive and integrated manner clinically appropriate medical care with the social support s and services that allow them to remain livi ng in the commun ity. SCAN currently serves 4,741 duals throughout Los Angeles County and propos es to expand to serve an additional 36,000 duals. The enrollee population w ould include all full benefit duals, aged 21 and older, for which SCAN w ould provide the full array of benefits to which they are entitled under Medicare and Medi-Cal , as well as supplem ental services including dental care, vision care, transpor tation, hearing aids and other item s and services (subject to reimbursement levels). SCAN Health Plan 17 To assist in the delivery of t services, SCAN will partner with he Medicare, Medi-Cal, and supplem ental the County Departments of Mental Health/Substance Abuse and Public Social Services, Public Guardian, the Area Agency o n Aging, Local Public Author ities, Independent Living Centers, CBAS, MSSP, and Rehabilitation Department offi ces. We will also engage in sub- contracting discussi ons with other health plans that have appropriate expertise in managing duals. The SCAN Model of Care, included as Appendix 10, is a coordi nated care management model distinctly designed for the dual eligib le population. The Model of Care begins with risk st ratification to identify members at the highest risk, and individualized assessment and team-b ased care planning t o determine how best to meet members' clini cal and social support needs. SCAN's model includes a suite of program s designed to tailor a mem ber's care to his or her unique needs, from healthy through end of life. Our persondescribed in more detail below: Risk Stratification and Com prehensive Assessm ent: SCAN uses a centered car e man agement approach is sophisticated risk-stratification algorith m to identify mem bers at highest ri sk, based on diagnoses, utilizatio n patterns, m edications, a nd responses to the biannual HRA. SCAN's m odel also relies on comprehensive assessment instruments that consider the multiple factors that can im pact the whole person--physical, SCAN Health Plan 18 functional, social, and behavioral. Assessments are based on validated instrum ents, including the SF-36, PHQ-9, and a variety of specialized screening tools. Individualized, Team-Based Care: Based on the com prehensive assessment, SCAN designs a pl an of care around the i ndividual, including targeted case management as needed, with active invol vement of the mem ber, family, and PCP as part of the Interdisciplinary Care Te am. All mem bers, regardless of health status, benefit from preventive strategies . More at-risk m embers, with chronic conditions such as diabetes, hypertension, dementia, CHF, or Chronic Obstructive Pulmonary Disease (COPD), and those suffe ring from disabilities (e.g., traumatic brain injury, amputations, mobility impairments, multiple sclerosis, and behavioral health/substance use diagnoses) are ma naged through our Geriatric Health Management & Mo nitoring (GHM) and Dis ease and Disability Support programs. Hospitalized memb ers and th eir caregivers receiv e coaching and inpatient cas e management, while mem bers leaving the hospital or nursin g home are guided by the Care Transitions Program. For m embers with memory impairments, specially trained case m anagers work w ith fam ily caregivers to coach them about disease course and behavioral m odifications. Proactive referral pro cesses have been established with caregiver agencies so me mbers are more likely to get the services they need. Thus, our multifa ceted care manageme nt approach is tailored to each individual's unique needs and health conditions. SCAN Health Plan 19 SCAN's case management program s ar e integrated by a co mmon software platform and supported by nurse and social complex care management. SCAN em work staff trained in geriatrics and phasizes tested approaches, such as motivational interviewing, coaching for se lf-management, caregiver support, and behavioral health coordination to help th e patient receive the best support possi ble for their care. A key element is the Inte rdisciplinary Care Team case conference with a SCAN physician and subsequent co mmunication with the m ember's PCP. The PCP plays an integral role, incl uding reviewing care plans, comm unicating with case managers, and participating in case conferences. Disease Management a nd Disability Support : SCAN's disease management programs are specifi c to th e chronic care needs of dual eligibles. Cas e managers educate mem bers about thei r disease process and managem ent, recognizing disease-specific sy mptoms and actions to take, when to call the doctor or seek urgent/emergent care, medication m anagement, n utrition, self-manag ement and healthy behaviors and advance care planni ng. The key disease states ar e CHF and COPD, b ut we also routinely help members manage m ultiple, co-m orbid conditions, such as diabetes. These are telephonic educational programs that follow guidelines established by t he Am erican College of Cardi ology/American Heart Association (ACC/AHA) and the Global In itiative for Chronic Obstructive Lung Disease (GOLD). SCAN Health Plan 20 Disability Support focuses on indivi duals with m obility challenges, amputations, traumatic brain injuries, depr ession, serious m ental illness, and other disabling conditions. Case ma nagers address the whole spectrum of needs with the goals of helping individuals live as independently as possible. Care Transitions: A master's level social worker ensures that members being discharged from the hospital or skilled nursing facility transition home safely and avoid unnecessary read missions. Care Tran sitions follows the Coleman Model, based on Four Pillars: 1. Use of a Personal Health Record to communicate information to primary and specialist physicians; 2. Reconciliation of pre- and post-hospital medications; 3. Knowledge of warning signs and symptoms; and 4. Understanding of appropriate follow-up care post-discharge. 9 Recognizing the age and vulnerability of SCAN's membership, SCA N added a Fifth Pillar regardi ng advance-care planning. Of ten, a hospita lization o r change in condition signals a time when mem bers and their fam ilies are open to discussing their preferences with regard to end-of-life care. Parry C., Coleman E.A., S mith J.D., Frank J.C., Kram er A.M. The Care Transitions Intervention: A Patient- Cente red Approach to Facilitating Ef fective Transfers between Sites of Geriatric Care. Home Health Services Quarterly. 2003: 22(3): 1-18. SCAN Health Plan 21 9 Medication Therapy Management : Managing com plex medication regimens is a primary focus acro ss the case manageme nt sp ectrum. SCAN provide s members at high risk for m edication issues (those t aking 8 or m ore medications) with skille d medication m anagement in a similar form at to those mem bers that participate in the CMS Medication Therapy Management Program . Such medication issues may include problems with health literacy, making it difficult for some memb ers to manage t heir medi cations; m ismatches between drugs and diagnoses; and use of non-recommended medi cations. In cases where a medication issue is anticipated, the m ember's case manager alerts the member to medication issues that should be raised with th e t reating physician. An IAH pharmacist who specializes in substa nce use and behavior al health will work in tandem with SCAN's pharmacists and will em ploy our PharmMD MedPro pharmacy software to identify potentially problematic risk profiles. Question 1.2.2: Describe how you will manage th e program within an integrate d financing model ( i.e. services are not treated as "Medicare" or "Medicaid" pai d services.) SCAN currently aggregates Medicare and Medicaid payments to provide the comprehensive, integrated model of care through our D-SNPs. We will continue to do so t hrough the Duals Dem onstration plan in Los Angeles County. SCAN does not treat the full compl ement of services as Med icare- or Medicaid-paid; rather, care is in dividualized without regard to the original sourc e of fundi ng. Our 20 SCAN Health Plan 22 years' experience as a So cial HMO makes SCAN uniquely qualified to operat e under an i ntegrated financing model. We look forward to learning m ore about t he financing structure to be used in the Demonstration. Question 1.2.3: Describe how the program is evidence-based. SCAN has developed and adopted C corresponding Case Management Guidelin linical Practice Guidelines and es that are designed to assist practitioners and case managers in the management of sp ecific conditions that are prevalent in the geriatric and disabled p opulations. Examples of SCAN's Clinical Practice Guidelines include practitioner guid elines for the treat ment of diabetes, COPD, and depression. Case Management Guidelines include guidelines for managing diabetes, substance use, chroni c pain, and screening and prevention. These guidelines provide a roadm ap for assessing needs and taking correspondi ng actions. The guidelines are based on nationally-accepted medical evidence and best practices derived from clin ical literature and ex Practice Guidelines are reviewed annua pert consensus. The Clinical lly by the Pharmacy and Therapeutics (P&T) Co mmittee, and the evidenced-bas ed guidelines for case managers are reviewed annually and pr ocessed through SCAN's Quality Management Committee. A list of SCAN's Clinical Pr actice and Case Managem ent Guidelines is attached at Appendix 11. SCAN Health Plan 23 To ensure consistent understanding among SCAN staff mem bers, we train staff annually on these tools. In addit ion, the gui delines are co mmunicated to our provider organizations in the following ways: o Evidence-Based Continuing Medi cal Education (CME) Program s. SCAN sponsors a robust perform ance im provement education program for our medical provi der partners and co mmunity physicians. SCAN is an accredited continui ng education provid er for physi cians, nurses, licensed social workers, and pharm acists. Web-based m odules, each with an by expert university faculty, who interactive case study, are created incorporate the lates t research data in to their presentations. The goal is to enhance practicing physician perform ance in caring for SCAN's older, complex, and disabl ed popula tion, as many providers have not received formal trai ning in geriatrics or care of the disabled. Current topics include Diabetes Management, Stroke Preve ntion, CHF, Depression Care, and Office-Based Assessment, with additional modules in development. o SCAN Provider Webpage . SCAN's website offers additional information and tools, including a training course on Hierarchical Condition Categories (called "HCC University"), tools su screening and the Six-Item Screener ch as the PHQ-9 for depression for cognitive screening, provider updates, formulary information, and multi-cultural resources. SCAN Health Plan 24 o Clinical Collaboration. Providers are an integral part of the SCAN Phar macy & Therapeutics Committee, participat e on planning co mmittees for SCANsponsored CME, and are included in SCAN's annual Geriatric Advisory Board (GAB) meetings. The GAB is com posed of national experts in a ging and health care that advise SCAN a bout incorporating new evidence-based models and best practices into the delivery of care. Question 1.2.4 : Explain how the program will impact the underserved, address health disparities, reduce the effect of mu ltiple co-morbidities, and/or modify risk factors. SCAN has developed culturally sens itive approaches to address our population's com plex health and social n eeds. Dem ographically, nearly half of SCAN's d ual eligibles are Hispanic, appr oximately 25 percent are White, and an additional 1 1 percent and 9 percent ar e African American and Asian/Pacific bers report not Islanders, respectively . Additionally, a bout 40 percent of mem speaking English well or at all, and 22 pe conflict with their doctor's advice. 10 Under the Duals Dem onstration, SCAN will identify m rcent believe that their health beliefs embers with the highest health risks, who are often th e same ones who have been underserved by the disjointed FFS system. They may have not had a medical home or continuous relationship with a primary care provider , or access to necessary preventive tests 10 SCAN Health Plan (2010). Internal analyses and survey. 25 SCAN Health Plan and screenings. Contrary t o t heir expe rience under FFS, these beneficiaries will receive care that meets their unique n eeds, including their cultural and linguistic needs. For example, we translate our printed materials into the threshold languages (English a nd Spanish throughout Californi a, and additionall y Vietnamese and Chinese in Northern California) language s; m any of our am bulatory and di sease management case managers are bilingua l; and we inform mem bers about free interpreter services that are available managers are sensitive to to them and to providers. SCAN' s case members' cultural preferences (including dietary preferences) in developing care plans. Perhaps most important, SCAN's Patient Assistance Line (PAL) is dedicated to assisting dual eligible members. Each m ember has their own "P AL" who they can call for information about benefits, how t o change doctors, tra nsportation referrals, or help getting used to the ne w procedures of m anaged care. P AL staff work to develop relationshi ps with t heir assigned mem bers, so that they can understand their preferences for care and comm unication. All P AL staf f are bilingual (English/Spanish), and new bilingual staff will be added as new threshold languages are identified. SCAN's program will also reduce the im pact of multiple co-morbidities and will m odify m embers' health risk factor s. Beneficiaries with complex health needs--those with CHF , COPD, and/or multiple co-morbidities--will receive SCAN Health Plan 26 targeted disease manageme nt services to help them manage their chronic conditions and lower their risk factors over tim e. For example, the CHF Disease Management Program tar gets mem bers w ith CHF who have been identified as high-risk through SCAN risk stratificati on algorit hm. Nurse case managers guide the member through educational pathways focused on understanding their disease, communicating with their doctors, identi fying warning signs and sym ptoms, and adhering t o their m edication, diet, and ex ercise regimens. S taff maintains strong connections with the member's doctor and medical group, so that if any concerning change is identified (e.g., if a mem ber re ports a w eight (flui d) gain) c are can be escalated. Furthermore, case managers are well-tr ained to work with m embers with diabetes, a prevalent cond ition in the dual eligible follow a specially-designed set of diab population. Case managers e etes clinical guidelines and educat members about the im portance of diabetic tests, including foot, eye, and kidney screening; modifying their diet; and incorporating exercise into their lifestyle. Selfmanagement skills also focus on regular ly checking blood sugars, ef fectively communicating with doctors, wearing prope r foot wear, and attending to foot problems before they beco me serious. SC AN has subm itted a SNP application to add a Diabetes Disease Management Program in 2013. Question 1.2.5: Explain whether/how the program could include a component that qualifies under the federal Health Home Plans SPA. SCAN Health Plan 27 SCAN uses a patient-centered, targeted, team-based care management model for individuals with chronic illnesses, co nsistent with the health hom es envisioned by the Affordable Care Act (ACA) and Ca lifornia's 1115 waiver. SCAN currently has a sizeable population of patients that w ill be eligible for h ealth home services based on the proposed eligibility criteria (e .g., asthma, diabet es, heart disease, obesity, m ental condition, and substance us e disorder, one seri ous and persistent mental health condition). For years, SCAN has been providing team-based health care and care coordination services to our mem bers us ing an evidence-based chronic diseas e model. The case management progra m has an Interdisciplinary Care Team consisting of physicians, nurse case managers (RNs), soci al workers, dieticians, pharmacists, and be havioral health worker s. The team meets weekly to discuss patient managem ent using a "holistic" or "whole person" approach covering t he clinical, pharmacological, behavioral, cu psychosocial aspects of the mem ltural, health literacy, econom ic, and ber's h ealth. An indivi dualized care plan is developed for each of our memb ers and is communicated to th e full team and the member's physicians (primary care and speci alists). Effective feedback is solicited from the physicians i nvolved in the care, a nd all aspects of care are planned to be patient-centric, taking into a ccount cost effectiveness, quality, evidence-based medicine, and patient preferences. SCAN Health Plan 28 The care management provi ded by the Interdisciplinary Care Team incl udes risk stratification to identify high risk members; comprehensive care management; individual and family support; member education on disease self-management; and support through m otivational interviewing leading to patient em powerment. The model also includes care coordinati on, health prom otion, comprehensive transitional care between settings, and referral to appropriate community and social support services. SCAN effectively uses hea lth IT tools to gather and analyze data, which is then used to link these mem bers to the appropriate care m anagement programs to fill any potential "gaps" in care. Question 1.2.6: Identify the primary challenges to successful implementation of the program and explain how these anticipated risks will be mitigated. SCAN anticipates several significan implementation of the program: o The large num ber of dual eligibles the State intends to m ove into managed care; o The expedited timeline for the Demonstration; o The unknown level of patient need a supports; o The reorganization of the current system to become a "one door ent ry" for duals to access health care and social services providers; o The impact of reimbursement reductions; and SCAN Health Plan 29 nd demand for health services and t challenges to the successful o Uncertainty surrounding beneficiaries' acceptance of the transition into a managed care model. Many of these challenges can be m itigated by using a phased approach to enrollment. Specifically, enrolling beneficiarie s in the m onth of their birt h, as was done with the SPD population, will allow plan s to make the m ost efficient use of their enrollment staff. In addition, esta blishing clear tim elines will help plans allocate sufficient resources and staff fo r the Annual Enrollment Period. However, if the expedited process becomes too burdensome, the State may want to follow the lead of Arizona and postpone implemen tation until 2014 to assure a successfu transition. To mitigate the uncertainty surrounding the potential health needs of ne wly enrolled dual eligible mem bers, SCAN intends to use our HRA instruments to accurately gauge mem bers' conditi on upon enrollment and the projected level of demand for services. We will use risk stra tification to ensure that each memb er l receives the appropriate level of serv ices. Our PAL Unit and cas e manageme nt staff will be key resources fo r determining the best way to manage each mem ber's care. In additi on, CMS and the State shoul d make available as much historical claims data and health status inform ation about newly enrolled duals as possible t o help the selected Dem onstration plans un derstand their expected health care needs and service utilization. SCAN Health Plan 30 Based on our experience with IAH a nd as a Social HMO, SCAN is well positioned to m erge the health care and soci al services elements to facilitate the transition to a "one door entry" sy stem for duals. Promoting comm unication among all stakeholders regarding the best wa ys to service the patient will help to ensure a successful transition, after a period of adjustment. As for the reduction i n reimbursement, managed care plans can successfully deliver better care and reduced costs if discount off of hi storical FFS costs, plans are paid based on a reasonabl and if the payments for individual e beneficiaries are risk-adjusted going forward. Finally, beneficiaries will support the State's proposal only if they truly believe that the care they will receive goi ng forw ard will be at least as good as what they currently receive. Plans m ust produc e a network of high-quality practitioners augm ented by su pport services that help patients live the life they want to li ve. Through our ext ensive cont racting and qualit y a ssurance processes, SCAN is prepared to deliver an integrated set of benefits of the highest caliber. Section 2: Coordination and Integration of LTSS Section 2.1: LTSS Capacity Question 2.1.1: Describe how you would propose to provide seamless coordination between medical care and LTSS to keep people living in their homes and communities for as long as possible. The cornerstone of SCAN's mission is caring for our members in a way t hat allows them to continue living as indepe ndently as possible i n the setti ng of t heir SCAN Health Plan 31 choice. Thus, it is critically im portant th at memb ers' medi cal care services be complemented by and coordina ted with community-based LTSS, including Adult Day Health Care ( ADHC)/Community-Based Adult Services (CBAS) Center, InHome Support ive Services (IHSS), and the HCBS waiver programs including MSSP, In-Home Operation waivers, Devel opmentally Disabled Services waivers, AIDS waivers, and the Assisted Living waiver. SCAN h as extensive experience work ing collaboratively with LTSS providers, seamlessly linking members with wrap-around services in our history as a Social HMO and within the IAH program . Based on our experience, we have inhouse experts who work closely with programs. SCAN is prepared to broa a wide range of L TSS providers and den the reach of these services in a coordinated and unified m anner, ensuring the development of a seam less process that will consist of open communication a nd include the m ember and their support network each step of the way. SCAN will continue to work collaboratively with County and City Area Agencies on Aging; Public Authority; individual providers; professional organizations, including a ll MSSP sites that serve the county; CBAS providers; and comm unity services and cont racted providers. The result will be a process that ensures our mem bers' need s are appropriately addressed through a system of care that accounts for all of the components found in the "Framework for Understanding Long-Term Car e Coordination" (Appendix E to the RFS). SCAN SCAN Health Plan 32 will facilitate additional collaborative wor kgroups as needed, and will enhance our existing Member and Community Advisory Committees to include representation from involved organizations. Th is collaborative approach w ill ensure that there is representation and input from the mem bers and their family and caregivers, PCPs, LTSS program s in the co mmunity, faith-bas ed entities, and other resources that make up the system of care. Question 2.1.2 : Describe potential cont racting relationships with current LTSS providers and how you would develop a reimbursement arrangement. SCAN will develop additional contract relationships with LTSS service and other community based service providers, si milar to those currently in place with our HCBS vendors, to deliver LTSS-type services as part of the Duals Demonstration. SCAN, both as a Knox-K eene-licensed health plan and through our IAH division, has sign ificant experience in deliv ering LTSS-type services. This experience has allowe d SCAN to develop effectiv e methods for contracting with these vendors, including i ncentivizing superior perform ance and implementing controls that guard agains t poor perform ance. Potential payment methodologies could include setting a pe r-case rate or a per-mem ber per-m onth rate, depending on t he service, the frequenc y of use, and the breadth of expected use across the population. Question 2.1.3: Describe how you would use Heal th Risk Assessment Screening to identify enrollees in need of me dical care and LTSS and how you would SCAN Health Plan 33 standardize and consolidate the numerous specific medical care and LTSS. SCAN has a valid assessment tools currently used for ber n eeds, ated HRA instrume nt that identifies mem particularly those in need of medical care and LTSS. For members of SCAN's DSNP who are identified as needing HCBS that are covered by the State contract, an initial HRA is conducted in the membe r's home by a field specialist and a corresponding telephonic assessment is c onducted by an RN. The assessment tool and processes have been approved by DHCS and meet State contract. SCAN's HRA is a 28-question instrume nt that is based on vali dated the requirements of the instruments such as the SF-36 and PHQ-9 (for depression). It includes questions on the critical assessment domains: physical and mental health, functional, social, and environmental. SCAN annually mails th e assessment in English or Spanish (depending on the mem ber's language pr eference). SCAN is prepared to expand the available languages to the other th reshold languages so that it may be completed in the mem ber's chosen la nguage. Mem bers and caregivers can also complete the questionnaire online. If members do not respond, a follow-up mailing is sent, followed by a rem inder call w ith a request to call the SCAN case management department. Ou r overall response rat e is high--approximately 60 to 70 percent--with dual eligibles only sli ghtly less responsive. Once the HRA is completed, the data is incorporated into SCAN's risk stratifi cation software that SCAN Health Plan 34 determines members' overall risk based on utilization, pharmacy, cost of care, and HRA data. Based on the HRA, a summary of actionable items is compiled and sent to the member's PCP. Under the Duals Dem onstration, SCAN will expand the current HRA process to incorporate any universal asse ssment tool provided by DHCS as well as additional screening information needed to appropriately assess m embers for all LTSS serv ices. Once a consolidated tool is in place, each completed assessment will be reviewed. As under our current pr ocess, if a mem ber responds to certain trigger questions, he or she will be auto matically referred to the appropriate care management progra m or LTSS servic interdisciplinary team will review the e for further needs assessment. An case, and the care planning process and service implementation will begin. High-risk cases will be reviewed by the SCAN Interdisciplinary Care Team, which includes a nationally recognized geriatrician, a nurse, a social worker, a clinical pharmacis t, a beh avioral health specialist, and a dietician. Question 2.1.4: Describe any experience working with the broad network of LTSS providers, rangi ng from home-and comm unity-based service providers to institutional settings. SCAN has extensive experience worki ng with a wide range of L TSS providers based on our 30-plus years as an MSSP provider and our experience as a Social HMO. Both the health plan a nd IAH have a long history of providi ng SCAN Health Plan 35 HCBS to NFLOC and dual eligible indivi duals, and coordinating with the network of care of each individual. Examples of services provided have included ADHC, MSSP, behavioral health, personal care, homemaking, transportation, transportation escort , respite care, hom e-delivered meals, telephone emergency response services, housing support and m inor home repairs, nutrition supplem ents, incontinence supplies, and durable medical equipment (DME). In working with LTSS providers, we have engaged in ongoing collaboration, communication, and m aintenance of our contractual and rei mbursement arrangements, ensuring high quality care d elivery. SCAN and IAH have collaborated with and trained both the LT SS providers and health plan/IAH staff, and have worked together on procedures for m onitoring com pliance and quality, ensuring appropriate delivery of services to the member. SCAN has partnered with both for-profit and not-for-profit agencies through direct collaboration, community workgroups, and contracts. Providers' services must cover the entire SCAN service area (encompassing several counties), and they must provide evidence of standards of care that meet State and Federal specifications. Question 2.1.5 : Describe your plans f or deliveri ng integrat ed care to individuals living in institutional settings. Institutio nal settings are appr opriate setting for some individuals, but for those able and wanting to leave, how might you transition them into the community? What processe s, assurances do you have in pl ace to ensure proper care? SCAN Health Plan 36 SCAN has well-developed protocols and Policies and Procedures for delivering care to mem bers residing in institutional settings. SCAN provides institutional Long Term Care (LTC) to dua l eligible mem bers who require m ore care than can safely be provided thro ugh hom e and comm unity-based program s. SCAN's Utilization Management (UM)/Co mplex Case Management (CCM) Department works with the facility and pr oviders of care to en sure that m embers meet criteria for placement, an d that they are receiving comprehensive quality care in the most appropriate and least restri ctive setting. SCAN clinical staff also identify a nd refer mem bers who require additional cas e manageme nt services. SCAN RNs review the MDS 3.0 form completed upon adm ission and quarterly thereafter. SCAN requires that contracted nursing facilities respond to changes in a member's health status (e.g., falls, emerge ncy department visits, significant weight loss, pressure ulcers, unexpected change in mental status) by notifying the treating practitioner within 48 hours . SCAN case man agers then follow up with the delegated provider organization, make any necessary refe rrals, and work with the facility to adjust the care plan. SCAN has extensive experience with tr ansitioning individuals who wish to leave an institutional setting back into th e community. SCAN's IAH division is an original and current contractor under the Money Follows t he Person Californi a Community Transiti ons (CCT ) project. Through t his program, IAH has worked SCAN Health Plan 37 with DHCS staff and other contractors across the State to help Me di-Cal recipients aged 18 years and older return to the comm unity living setting of their choice after residing in a nursing facilit y. Through State-validated assessment tools and qualitative measures, this program performs a co mprehensive assessment, designs a complex care plan, and begins the im plementation on behalf of the patient while they are still living in a nursing facility. Services that may be performed during this period include fi nding and setting up hou sing; hom e modification to ensure accessibility; arranging for IH SS servic es; linking the m ember to other waiver programs, such as MSSP and the In-Home Operations waiver program; medication management training; transfer of benefi ts for institutional setting to comm unity dwelling; re-establishing SSI paymen ts; and obtaining DME. The work of transitioning long-te rm memb ers from a nursing home requires creativity and intensive effort to m arshal varied commu nity resources to provide "wrap" support as the individual returns to the co mmunity. Quality assurance is provided through case conferencing with the direct car e t eam on a m onthly basis, and with t he extended team quarterly and as needed . Social workers also participate in the nursing facility interdisciplinary team meetings to ensure the necessar y collaboration to prepare for the individual's return to the community. Section 2.2: IHSS SCAN Health Plan 38 Question 2.2.1 : Certify the intent to develop a contract with the County to administer IHSS services, through i ndividual contracts with t he Public Authority and County for IHSS administration in Year 1. The contract shall stipulate that: o IHSS consumers retain their ability to select, hire, fire, schedule and supervise their IHSS care provider, s hould participate in the development of their care plan, and select who else participates in their care planning. o County IHSS social workers will use the Uniform Assessment tool and lines, authorize IHSS services, and guided by the Hourly Task Guide participate actively in local care coordination teams. o Wages and benefits will continue to be locally bargained through the Public Authority with the elected/excl usive uni on that represents the IHSS care providers. o County IHSS programs will continue to utilize procedures according to established federal and stat e laws and regulations under the Duals Demonstration. o IHSS providers will continue to be paid through State Controller's CMIPS program. o A process for working with the Count y IHSS agency to increase hours of support above what is authorized under current statute that beneficiaries receive to the extent the site has de termined additional hours will avoid unnecessary institutionalization. SCAN Health Plan certifies that requirements. we will com ply with all above Question 2.2.2 : Wit h consi deration of t he LTSS Framework in Appendix E that emphasizes consumer choice, and in consideration of the approach taken in Year 1 as described above, please describe the interaction with the IHSS program through the evolution of the Demonstration in Years 2 and 3. Specifically address: o A propose d care coordination model with IHSS, including the referral, assessment, and care coordination process. o A vision for professional trai ning fo r t he IHSS worker including how you would inc entivize/coordinate t raining, including with regar ds to dementia and Alzheimer's disease. o A plan for coordinating emergency systems for personal attendant coverage. SCAN Health Plan 39 SCAN and IAH have a long history of coordi nating care for t he frail population with IHSS. Currently, we collabor ate with IHSS case workers to ensure that mem bers are receiving appropriate car e. If, for exam ple, a sudden change in the member's condition occurs or the cu rrent IHSS hours are not adequate, SCAN will use contracted agencies to provid e supplem ental care so the member's care needs are met. S CAN and IAH staff wil l then help the m ember communicate with IHSS to ensure that the appropriate services are in place. Most recently, SCAN hosted a coordi Authority Representatives in Novem nating meeting with IHSS Public ber 2011 t o learn about how the IHSS programs function i n Los Angeles, Riverside, San Bernardino, and San Diego Counties, and to explain how SCAN's D-SNP operates. Our goal was to pursue opportunities to cooperate going forward in light of anticipated Duals Demonstration activities. Additional m eetings and conversations have occurred to continue this progress. SCAN has recei ved letters of agreement from the Los Angeles County Public Authority and t he San Diego County HHS Agency and the Public Authori ty t o work in good faith on t he Duals Dem onstration project (se e Appendix 7). During Year 1 of the Duals Dem onstration, SCAN will continue discussions with the County and/or local IHSS o ffices and Public Authorities. The "Framework for Understanding Long-Te rm Care Coordinati on" (Appendix E to SCAN Health Plan 40 the RFS) will serve as the foundation for di scussion with IHSS to develop a pla n toward full contractual relationships that: o Establish a care coordina tion model including the re ferral, as sessment, and care coordination process; o Ensure member choice of caregiver; o Ensure appropriate training, supervision, and payment of caregivers; o Extend and incorporate evidence-base d disease- and disability-specific education and training for the IHSS wo rker and memb er/caregiver, building on those interventions mentioned in section 1.2.3; and o Provide continuous care for members when an IHSS worker is not available, including the use of agency care in emergency situations. As m ore details beco me available on how the IHSS program will interact with managed care plans within the Dem onstration, SCAN will continue these discussions in pursuit of contractual relationships with the public authorities. Section 2.3: Social Support Coordination Question 2.3.1 : Certify that you will provide an operational plan for connecting beneficiaries to social supports that includes clear evaluation metrics. SCAN Health Plan certifies that we will comply with the above requirement. Question 2.3.2 : Describe how you will assess and assist beneficiaries in connecting to com munity social programs ( such as Meals on Wheels, CalFresh, and others) that support living in the home and in the community. SCAN Health Plan 41 A key part of the HRA and assessment process evaluates how members selfmanage in their homes. This include s ADL and IADL functional ability, hom e setup, access to food and ot her basic needs, social support, and financial resources. Where there are d eficits that could put members at risk, SCAN will coordinate the necessary array of services. For exam ple, a mem ber who cannot transport him self to a doctor's appointment for m onitoring of his chronic health conditi ons would receive both transportation and transportation escort services to help him get out of the house and return safely to hom e. A mem ber who needs help shoppi ng and preparing meals and who, without proper nut rition, would be at risk of poor health and having to enter an institutional se tting, would be linked to hom e-delivered meals, congregate meal sites, and othe r food assi stance program s. If a person is isolated and lacking social support, SCAN staff would li nk them to a friendly visitor program or senior center for regu lar social interaction and visits. SCAN's long experience as a Social HMO and M types of comm unity linkage s assists us SSP pa rticipant shows that using these in enabling our m embers to avoid unnecessary institutionalization. By asse ssing each memb er's needs and matching those needs with the right services, we keep our m embers living independently i n their own homes, in furtherance of the SCAN mission. Question 2.3.3 : Describe how you would partner with the local Area Agency o n Aging (AAA), Aging and Disability Re source Connection ( ADRC), and/or Independent Living Center (ILC). SCAN Health Plan 42 SCAN wil l engage existing partners hips in each county and will develop new relationships with c ounty and private aging a nd disability services to coordinate support e fforts for our m embers. The g oal of this collaboration will be to establish seam less transitions and fa cilitate access for mem bers in need of community services. SCAN will look at st rategically staffing case managers onsite at some program locations to help bridge gaps, as well as to build rel ationships and familiarity with the agency and popul ation while ensuring seam less care. We will establish two-way co mmunication with the Area Agency on Aging, Independent Living Centers (ILCs), a nd Aging and Disability Resource Centers, where app licable. For example, SCAN is al ready an established partner with LA County Community and Senior Services/Area Agency on Aging. For more than 13 years, SCAN's IAH division has provided Linkages, as well as Title IIIB and IIIE care management and support services, to the southern Los Angeles County region on behalf of the AAA. Linkages is de signed to prevent the premature or inappropriate institutionalization of frail, at-risk elderly and functionally im paired adults, aged 18 and ol der, by provi ding care management and com prehensive information and assistance ser vices. IA H and SCAN also work collaboratively with the Los Angeles City Departme nt of Aging on several comm unity workgroups and in comm unity and senior centers to ensure that the needs of this population are m et through outreach, edu cation, and coordination. IAH als o SCAN Health Plan 43 currently collaborates with ILCs and ot her community resources through the CCT Program. Question 2.3.4: Describe how you would part ner with housing providers, such as senior housing, residential care facilities, assisted living facilities, and continuing care retirement communities, to arrange for housing or to provide services in the housing facilities for beneficiaries. Both SCAN and IAH serve mem bers who reside in senior and low-incom e housing, as well as in assisted living facilities and retirem ent comm unities. Care management staff have esta blished relationships with resident coordi nators and with on-site support staff in these comm unities. The nature of these partnerships includes collaboration in meeting the n eeds of indivi dual mem bers (where applicable consents for discl osure have been signed by t he client), as well as providing group wellness and education services to residents that support healthy living and home safety. SCAN's networked relationshi ps provide us with an awareness of housing availability, allowing SCAN to support the m ember through the application process as well as to assist w ith hom e setup and m onitoring with t he support of existing building requirem ents. Existing re lationships will prove essential where housing m anagement or staff c an alert SC AN in t he event of an em ergency or when a change in functional st atus is not ed, provided that proper consents are in place. Thi s will enable interventions befo re a person loses his or her housing for SCAN Health Plan 44 failing to pay rent, or becomes at risk of a medical event that may impact his or her safety or ability to live in the community, such as a fall. In addition, SCAN is pa rtnering with United Cerebra l Palsy (UCP) to help manage the care of beneficiaries with complex social needs. Currently, UCP assists beneficiaries with disabilities by provid ing the m with independent, "smart" housing options that include rem ote mon itoring capabilities, oversight of daily needs such as nutrition, and access to direct care workers. Section 3: Coordination and Integration of Mental Health and Substance Use Services Question 3.1: Describe how you will provide seamless and coordi nated access to the full array of mental health and substance use benefits covered by Medicare and Medi-Cal, including how you will: o Incorporate screening, warm hand-o ffs and follow-up for identifying and coordinating treatment for substance use. o Incorporate screening, warm hand-o ffs and follow-up for identifying and coordinating treatment for mental illness. SCAN will leverage our existing ro bust m edical care m anagement infrastructure to incorporate and provide mental health and substance use treatment benefits in accordance with Medicar e and Medi-Cal covera ge requirements. Having reviewed the Framework for Unders tanding Mental Health and Substance Use and t he relat ed Technical Assistan ce document (Appendices F and G to the RFS), SCAN understands that m oving into this new service delivery m odel will require carefully thought-out and coordinated screening, assessment, and treatment that supports the mem ber through the syst em of care. To establish the seam less SCAN Health Plan 45 coordination of access to ment al health and substance use care that incl udes warm hand-offs of the m ember, SCAN will work with county and comm unity providers and use our own experience with deliv implementation plan. SCAN will bring our current knowledge and experience with providing ering these services to creat e an behavioral health and substance use servi ces to thi s conversation. We recognize that treatment and m anagement of behavi oral health issues and inappropriate substance use is an important component of stability and wellness. Currently, all of SCAN's contracted medical groups are re quired to provide both inpatient and outpatient behavioral health services, in cluding detox and substance use treatment. Treatment for medication misuse, a common problem in older adults, is included in the scope of assessment and treatment . How the medical groups provide thi havioral health provide rs, such as r groups hire their own co-located s varies--some groups contract with large be Value Options and Windstone, while othe behavioral health staff. In addition, there are areas where members have been using the County Mental Health system, coupled with provider involvement. Furthermore, SCAN has e xperience coordinating behavioral health services through IAH's in-home m ental health se rvices program , Innerlinks Advantage. This program offers in-hom e m ental hea lth services to Spanish- a nd English- speaking NFLOC clients of the MSSP and Linkages programs. This program fills a SCAN Health Plan 46 unique niche for m embers who either cannot or wi ll not leave their homes due to mobility, agoraphobia, or other behavioral diagnoses, or when county m ental health providers for that area are not available. At present, IAH has relationships in place with LA County Mental Health th System of Care Committ ee. We also rough m embership on the Older Adult have referral-based and collaborative relationships with Heritage Clinics, Pacific Clinic s, and LA County's FACTS Program, all of which are contracted county mental health providers. We expect to form similar partnerships in the other counties in which we participate in the Duals Demonstration. To provide seamless access, SCAN will work with both county departments of mental health and alcohol and drug programs to establish a service delivery plan and contracts to prevent the interruption of services for existing patients in Year 1. SCAN will initiate an interdisciplinary review team with county providers to ensure a shared care plan and continued c ontinuity of care. SCAN will also add an additional com ponent in Year 1 usi ng I AH's Innerlinks Advantage services to wrap around and reach those in the home who, due to their m edical condition, cannot reach traditional m ental health settings but still need these critical services for their stability and wellbeing. SCAN will also create a "no wrong d oor" access point for newly identified members who are i n need of either mental health and/ or substance use treatment. SCAN Health Plan 47 As a part of the assessment process, SC AN will utilize the following mental health and substance use assessments to identify needs and facilitate referral to one of the contracted or in-house services for all dual eligible members. These tools include: o PHQ-9: Depression Screen o Six Item Screener: For Cognition o DASS: for Depression, Anxiety, and Stress o CAGE 1: For Alcoholism and Drug Abuse o Bipolar Diagnostic Criteria o For further assessment and diagnosing: o Geriatric Depression Scale (GDS) (short version) o St. Louis University Mental Health Status (SLUMS) examination: For Cognition When a member's screening or assessment indicates evidence of risk based on standardized criteria included with each tool, the case will be referred to the behavioral health specialist for review an d referral to the appr opriate subcontractor for a full evaluation. The behavioral hea lth specialist will c ontact the mem ber to discuss and explain t he referral. If the m ember accepts, the member will be linked with a contract agency through a confer specialist, mem ber and agency staff ence cal l between the behavioral health to facilitate a warm handoff. Once the evaluation is complete, a treatment plan w ill be developed and se rvices will begin. SCAN Health Plan 48 Interdisciplinary case conferences will be held on an a s-needed basis, but beginning on a m onthly basis. These will be coordinated by the m edical health director and t he behavioral health spec ialist to ensure care coordination, track outcomes, and identify the need for ongoing services. Throughout Year 1, SCAN will engage partners to enhance the service deliv in stra tegic planning with our ery m odel for Years 2 and 3 of the Demonstration, including co-l ocation in physician offices to increase access to assessment and care. Question 3.2 : Explain how your program would work with a dedicated Mental Health Director, and/or psychiatrist quality assurance (preferably with training in geriatric psychiatry). The Ment al Health Director's role wi ll be to oversee all services and contractors through an interdisciplinary team review and quality assurance process, including collecting car e plan outcomes data to identify program improvem ent opportunities. Key mem bers of the interdisciplinary team will include a geriatric pharmacist specializing in mental health and substance use issues, a consultant psychiatrist, and a behavioral health specialist or mental health clinician. This team will be responsible for quarterly case re significant change in the member's n view (m ore frequently if there is a eeds), including review of care plan outcomes, changes in condition, and ensuri ng that all disciplines involved in the member's care are inform ed. The Mental Health Direct or will oversee the use of SCAN Health Plan 49 evidence-based practices in all treatment modalities and will also create and deliver subject specific trainings to enhance the clinical and assessment practice skills of SCAN staff. Question 3.3: Explain how your program support s co-location of services and/or multidisciplinary, team-based care coordination. Many of SCAN's contracted provi ders al ready co -locate behavioral health services with primar y care. Fo r memb ers who may be reticent to seek behavioral health car e, having the two services in one place f acilitates access. SCAN's contracted providers have offices throughout the region, making community access readily available as soon as the Dem onstration begins. In addition, the use of Innerlinks Advantage will bring access to treatment to those who are una ble to go to a clinic setting due to behavioral and physical limitations. All SCAN and IAH program s function around the use of m ultidisciplinary teams to support the member. IAH teams have a public health nurse, social worker, geriatric pharmacist, and where they will be involved, a physician. SCAN's Interdisciplinary Care Team s have a me mbership of physic ians, nurses, LCSW behavioral health speci alists, geriatrician s, pharm acists and di eticians, as well as other disciplines as needed. This approach is an integral part of the SCAN Model of Care and will continue when expanding to bring these services to our mem bers. In this new model, we will also bring all involved cont actors and fam ily supports to the dialogue to ensure the goals set are being met. SCAN Health Plan 50 In Years 2 and 3 of the Dem onstration, SCAN will work to further co- location of services in medical offices and clinics throughout the county and the provider network. Question 3.4 : Describe how you will include consumers and advocates on local advisory committees to oversee the care coordinat ion partne rship and progress toward integration. SCAN has an established and growi ng Mem ber and Community Advisory Committee in place to support the enhancem ent of SCAN's Model of Care. This committee includes strategic representa tion from different consti tuencies, including mental health, comm unity servi ces, long-term care, caregiver services, cultural needs, and consul tation from the Area Agency on Aging, as well as dual eligible mem bers and fam ily mem bers. This committee will be expanded to include substance use services, independe nt living center services, as well as CBAS an d additional health plan members and consum ers to help us strengthe n, monitor and im prove care coordination as th is new system of care is form alized and launched. In counties outside of LA, an area-specific Member and Community Advisory Comm ittee will be establishe evaluation. The co unty comm ittees will assurance metrics, and will d to provide county-level input and meet quarterly, will review quality help ensure the delivery of patient-centered care in which both medical and behavioral health se rvices are delivered in an increasingly integrated manner. SCAN Health Plan 51 Section 3.2: County Partnerships Question 3.2.1: Describe in detail how your mode l will support integrated benefits for individuals severely affected by me ntal illness and chronic substance use disorders. In prepari ng t he response, keep in mind that your system of care may evolve over time, relying more heav ily on the County in Year 1 of t he Demonstration. ( See Appendix G for t echnical assistance on coordi nating and integrating mental health and substance use services for the seriously affected.) SCAN will build on the ex isting foundation of coor dinated services to further integrate health care services with mental health, substance use treat ment and LTSS services for all, including th ose affect ed by co-occuring disorders. Individuals who are severely im pacted by mental illness and substance use are in greater need of wrap-around support ive services so that interventions and assistance can occu r expeditiously when a memb er is experiencing stressors in order to maintain stability and prevent a psychiatric or medical emergency. As noted in section 3.1, SCAN will build upon our com prehensive medical care management model and will bring county departments together with contract providers to create an individualized delivery pla n. The plan will provide for seamless entry and continuation of county services for Year 1, coordinated with the members entire care team . SCAN will take th e lead by using the expe rtise of its own Interdisciplinary Care Team, which has membership of physicians, nurses, a LCSW behavioral health specialist, a geriatrician, a pharmacist and a dietician, and adding t he county partners t o review complex cases and es tablish treatm ent recommendations and measureable care pl SCAN Health Plan an goals. This will also include the 52 potential full array of LTSS program s as involved to ensure all services further the progress towards stability and meeting goals that will help the mem ber and his or her support system manage the m ember's health more effectively so that he or she can remain in the community. Question 3.2.2: Provide evidence of existing loca l partnerships and/or describe a plan for a partnership with the County for provision of mental health and substance use services to the seriously a nd persistently ill that includes measures for shared accountability and progress toward integration in the capitated payment by 2015. o Describe how you will work with County partners to establish standardized criteria for identifying beneficiaries to target for care coordination. o Describe how you will overcome barri ers to exchange information across systems for purposes of care coordination and monitoring. SCAN and IAH currently work with count y mental health and substance use services in a num ber of ways, ranging from collaboration on service area planning activities such as the Older Adult Syst funding and service strategy resulting fro em of Care workgroups (to im plement m the Mental Health Services Act (MHSA)) to coordination with county prov iders for individual service provisi on to members. SCAN and IAH staff also serve on joint public health taskforces with local providers and co mmunity services to inform our deli very of m ental health services. These relationships are a natura county and key stakeholders l point of entry to bring together the to develop a service delivery plan that includes specific responsibilities, quality assurance and monitoring, and a payment structure and responsibil ity for risk. We also have SCAN Health Plan received some lett ers of intent to 53 collaborate in good faith w ith County departments respons ible for m ental health and substance use services (see Appendix 7). We envision a phased plan that will include the county, its contractors, mental health and SCAN's interdiscipl inary team, and expert s in the field of substance use to establish evidence-base members through screening and outre d standardized cr iteria for identifying ach, and develop treatment approaches techniques to target and c oordinate care for these i ndividuals. This will build on SCAN and IAH's existing criteria for case management and referrals to ensure that all members potentially im pacted by m ental health and substance use issues have full access to services and are not lost in the transition. Key findi ngs of the California Mental Health and Substance Us e Needs Assessment include that the exchange of information and data is currently a barrier in the care system and should be addre ssed. SCAN will work to overcom e this challenge by partnering with contractors improve the sharing of inform to bri ng current technology system s to ation in additi onal to traditional telephonic interactions. The planning group will also use existing protocols and develop new ones as needed to exchange information. Section 4: Person-Centered Care Coordination Question 4.1 : Describe how care coordi nation would provide a person-centered approach for the wide range of medica l conditions, disabilities, functional limitations, intellectual and cognitive ab ilities among dual eligibles, including SCAN Health Plan 54 those who can self-direct care and also disease. those with dementia and A lzheimer's The complex health and social needs of the dual eligible population m akes person-centered car e essentia l. Under the SCAN m odel, each participating dua l eligible member will designate a physician or clinic as his or her PCP. The patientcentered care delivery m odel functions a s a mem ber's health hom e, focusing on care im provement and enhancement throug h the member' s dedicated PCP, an interdisciplinary team, me mber (and caregiver or fa physician education and support, and mily mem ber) education, ogy t o use of information technol communicate and support the provision of care. As described in section 1.2.1, i ndividual assessm ent and care planning ar e central to integrating the range of serv implements specific assessment tools in ices required by dual eligibl es. SCAN conjunction with the expertise of our risk for Interdisciplinary Care Teams t o focus on patients who are at greatest worsening conditions and hospital utiliz ation. SCAN uses individual assessm ent tools and t echniques to strati fy members based on t heir specific needs and/or risk. These tools and techniques are best practi ces that are successful in identifying and/or predicting risk for chronic conditi ons and disabilities ba sed on past medical claims data, pharmacy data and laboratory result s, di agnosis inform ation, and information from beneficiary-com pleted su rveys including disa bility level (i.e., limitations in activities of daily living). SCAN Health Plan 55 SCAN will place particular em phasis on the m anagement of m ental and cognitive diseases and conditions, whic h will require additional mental an d behavioral health services that coordinat e with the patient's prim ary care health home an d are part of the interdiscip linary t eam. The behavioral health interdisciplinary team will be co mprised of a pharmacist, licensed behavioral health providers such as Licensed marriage/family therapists or psycho Clinical Social Workers (LCS logists, registered nurses, W), and care coordinators. For be havioral health services that are not deli vered at the patient's primary care location, alternative treat ment sites will meet the beneficiary's medical, psychol ogical, and functional st atus needs and preferences, and may include a medical office where medical and psychiatric care are co-located, or i n the mem ber's hom e (which includes a nursing hom private residence, or telephonically). Once memb ers are determin ed to be eligible for disease management, e, assisted living facility, disability support or case management, care team s work with them to understand their needs and selectively target the type and level of services called for. A plan of care will then be developed and executed in collaboration with the patient's PCP and the patient (and hi s or her caregiver , if appropriate). The focus of this entire patient, including health goals and treatment plan will be to care for the cultural preferences, communication, coordination, and access. SCAN Health Plan 56 SCAN's care planning process will incorporate: o Input from the patient regarding personal health goals, preferences regarding care, understanding of health status, language and cultural preferences; o Assessment tools to identify patient needs, goals, and readiness/m otivation for change, and to track chang es in the patient's health status on an ongoing and regular basis; o Review of the patient's encounter and utilization data, pharmacy utilization data, and assessment questions across m ultiple domains (i.e., chronic illness, medication, cogniti ve, social-psychol ogical, spiritual, self-man agement skills, community resource needs, preven tive services, and access to care); and o Data from assessment informs the care specific to the patient. Care management program s will work w ith patients to ensure care plan adherence, timely access to primary car e, preventive health referrals, im proved plan and interventi ons designed self-management o f chronic conditions , and medication reconciliation. Case managers help m embers manage their car e by recognizing sym ptoms and actions to take, when to call a doctor or to s eek emergency car e, medication management, nutrition, self-managem ent and healthy behaviors, and advance care planning. Given the need for strong coordinati SCAN Health Plan on and successful transitions between 57 providers, several disease man agement a nd disability support programs will be a major focus under the Duals Demonstration: o Complex Care and Disease Management including: o CHF o Diabetes o COPD o Chronic Kidney Disease (CKD) o Depression o Disability support o Behavioral health care coordination, including dementia care o Medication therapy management SCAN's experience serving the Ar izona ALTCS disabled and aged population have resulted in considerable e xpertise in serving a range of disabilities including behavioral (schizoaffective a nd anxiety disorders, subst ance use, schizophrenia), m obility, visual and heari ng im pairments, m ultiple sclerosis, and traumatic brain and spinal cord injuries. Question 4.2: Attach the model of care coordina tion for dual eligibles as outline d in Appendix C. This will not count against any page limit. Please see attached Appendix 10. Question 4.3 : Describe the extent to which pr oviders in your network currently participate in care coordination and what steps you will take to SCAN Health Plan 58 train/incentivize/monitor prov iders who ar e not experienced in parti cipating i n care teams and care coordination. SCAN's contracted provi der groups are act ively engaged in car e coordination efforts and we work with these groups to em phasize the im portance of continuity of care. U nder a delegated m odel, SCAN contracts with provi der groups to take on care coordination ac tivities. Through our initial contracting process and ongoing m onitoring and overs ight activities, SCAN en sures that delegated provider or ganizations are perform ing a ll delegated responsibilities, including care coordination, to meet Medicare and Medi-Cal standards. In addition, providers are a key mem ber of the patie nt's Interdisciplinary Car e Team, which meets regularly to discuss the patient's c ondition and interventions that have been undertaken. Under the Dem onstration, SCAN will con tinue to engage w ith our provider groups to ensure appropriate care coordina tion for dual eligibles. In light of the additional services that will be brought u nder the SCAN u mbrella, it is even m ore critical that providers are consulted regu larly, whether in person, by phone, or virtually, to ensure that m embers are receiving the right care and social services at the right time. We will continue to monitor provider performance in this regard and will continue to provide regular CME a patient care. nd training to teach best practices for SCAN Health Plan 59 In SCAN's experience, perfo rmance-based incentives shared with providers lead to hi gher-quality care for beneficiar ies. For exam ple, structuring provider payments in line with the CMS 5-Star System for Medicare Advantage plan s incents our provi ders to stri ve for th e hi ghest perform ance on qualit y measures. Depending on the payment structure determ SCAN will consider ways to incentivize care coordination. Section 5: Consumer Protections Question 5.1 : Certify that your organization will be in compliance with all consumer protections described in the forthcoming Demonstration Proposal and Federal-State MOU. Sites shall prove compliance during the Readiness Review. SCAN Health Plan certifies that requirements. Section 5.1: Consumer Choice Question 5.1.1 : Describe how beneficiaries will be able to choose their primary care provider, specialists and participants on their care team, as needed. SCAN support s control and c hoice for t he indivi dual, from the enroll ment process to the choice of provi der to th e manner i n which services ar e received . Upon enrollm ent, SCAN m embers receive a list of PCPs that participate in the SCAN network. This expansive network assures wide-ranging consumer choice. we will com ply with the above ined for the Duals Dem onstration, our provi der groups to ensure seamless Patients receive information regarding lo cation of physician o ffices and language spoken, and every effort is made to match patients to appropria te caregivers based on the patient's age, functional abilities, and health status. Patients also have access SCAN Health Plan 60 to SCAN's robust panel of specialists. PC Ps and mem bers work together to find the specialist that meets the m ember's needs. Shoul d a m ember question a provider's diagnosis, treatment plan or recommendation for surgery, for exam ple, SCAN uphol ds the mem ber's right to a second opi nion. Finally, SCAN acknowledges that fee-for-service mem bers who enroll into the Demonstration have a right to keep their current provi ders for up to a year, even if the provider does not j oin the SCAN network. For pa yment purposes, we would treat those providers as we do today, on a fee-for-service, out-of-network basis. SCAN believes strongly in t communication. If a m he im portance of effective patient-provider that he or she cannot communicate alist or a case manager, he or she can ember believes effectively with his or her PCP, a speci request a change. Specifically , memb ers may change their PCP and/ or m edical group once per month, and can request a second opinion from a different specialist if they are facing surgery or a serious i llness. If a mem ber feels he or she cannot communicate easily with his or her case manage r or any other m ember of the care team, his or her Personal Assistance arrangements for them. Question 5.1.2 : Describe how beneficiaries will be able to self-direct their care and will be provided the necessary s upport to do so in an effective manner, including whether to participate in care coordination services. Line "PAL" can make alternati ve SCAN Health Plan 61 Members always retain their ability to make choices about their providers and their desired level of care coordinati on. SCAN is co mmitted to working with each m ember and hi s or her selected hom e car e assistant to creat e the right care management plan for the patient. SCAN' s self -directed attendant care model (SDAC) in Arizona has helped members learn about their options and achieve their goal of self-directing care. Th e program offers pati ents tips on how to select and manage a car egiver when they enroll. Along the way, patients recei ve ongoing education and support to help them be successful. Ensuring that care is provided in a member-centric manner is central to SC AN's mission, and our experience shows that patient outcomes and satisfacti on are im proved when patients and their caregivers play an active role in the asse ssment process, in care planning, and i n making choices that best meet the indivi dual's unique needs. The individual stands at the core of the developm ent and ope ration of our care ma nagement model--the member's needs, goals and desires are at the center of all care planning activities. Therefore, under t he Duals Dem onstration, SCAN will provide mem bers opportunities to self-direct their care, along with caregivers and family members. Section 5.2: Access ness review process you will Question 5.2.1 : Certify that during the readi demonstrate compliance with rigorous st andards for accessibility established by DHCS. SCAN Health Plan certifies that we will comply with the above requirement. SCAN Health Plan 62 Question 5.2.2: Discuss how your program will be accessible, while considering: physical accessibility, community accessibility, document/inform ation accessibility, and doctor/provider accessibility. Physical Accessibility: SCAN's Quality Management Department completes pre-operational Facility Site Reviews (FSRs) that assess the physical accessibility of all co ntracted entities, including the accessibility of stairs and elev wheelchair accessibility in cluding ramps, wide door bathrooms, electric exam ators, s, handicapped-accessible tables, imag ing equi pment such as X-rays being nd ori entation for those with visual accessible and com fortable, and signs a impairments. SCAN's entire ne twork of facilities providing care, and high volum e provider offices, have passed the FSRs. Delegation Oversight Review Co All F SR findings are rep orted to the mmittee for approval or development of a corrective action plan. Should the provider not m eet the standards identified, the committee will mak e reco mmendations up to and including term ination of the provider site from the SCAN network. S ubsequent site re views are scheduled every 3 years for PCPs that provide care to SCAN dual eligible members. Community Accessibility : Community and geogra phic accessibility are evaluated by our N etwork Management De partment prior to contracting with provider groups and facilities. SCAN curre location and network accessibility. SCAN ntly meets the DHCS standards for uses network provider data, enrollee y residence data, Quest Analyti cs software , and CMS criteria that include count SCAN Health Plan 63 level m inimum numbers of providers and tim e/distance standards t o ensure our provider networks are adequate to m eet the needs of current and future enrollees. Ninety (90) percent of enrollees m ust have access to at least one provi der within the time/distance standard for t hat provider type and county. These criteria can be modified to meet DHCS requirements, including but not limited to adding provider types such as long-te rm care facilities a nd adding Medi-Cal eligible and enrollee residence data. Facilities m ust also be in locations accessible by public transportation and free of hazardous access barriers. Document/Information Access ibility: SCAN is in co mpliance with Section 508 of the Rehabilitation Act a nd is committed to ensuring that all our written communications are easy to read and navi gate. For example, the SCAN website is designed for ease of reading and navigati on and allows for enlarging of font size. Alternative types of m aterials are ava ilable: print and telephonic comm unication, including TDY lines and f ace to face and telephonic interpreters. SCAN i iendly communications whic h reflect s committed to senior and disabled-fr considerable research of th e required standards and publ ished research about older and disabled individual's perceptual abilities and the adaptive mechanisms that can assist. As an example, SCAN uses high contrast primary colors in all of our printed materials and on t he website, since older a nd disabled individuals may have m ore difficulty with m uted colors and low cont rast. Communications are in a 14-point, SCAN Health Plan 64 sans serif font called Futura, which is easier to read than letters with a serif. All written communications are ch ecked for readability at a 6th grade read ing level. Incoming member telephone calls are always answered by a live person; we do not use automated system s or telephone t rees for incom ing calls, as members have indicated they are di fficult to use. We have dedicated 1-80 0 num bers set up for members, as well. Doctor/Provider Accessibility : As described in Adequacy, SCAN is com Section 7, Network pliant with th e geographical and physician type accessibility requirements. SCAN ensures th at enrollee linguistic needs are met by comparing enrollee and PCP languages and taking appropriate action, including but not li mited to offering t ranslation se rvices that are available 24 hours a day, seven days a week; working with delegate d provider groups to contract providers who speak and write the requi red languages; and reaching out to enrollees to assist them with finding PCPs in their areas who speak their language. In addition, offices and facilities are required to provi de service during nor mal business hours, and m any providers offer urgent care ce nters with extended ni ght and weekend hours. In an emergency, m embers can ac cess any hospi tal worldwide at any tim e. If memb ers report a lack of access, SCAN investigates the co mplaints with the provider group, t racks com plaints, and reviews trends. If necessary, Corrective Action Plans are structured and monitored. SCAN Health Plan 65 Question 5.2.3: Describe how you communicate information about the accessibility levels of providers in your network to beneficiaries. SCAN co mmunicates the accessibility leve ls of providers to patients in a variety of ways. The Evidence of Covera ge document, the provi der directory, benefits highlights, the SCAN website and the PAL Unit all serve as prime sources of information for members about the accessibility of their providers. For instance, the Evidence of Coverage document, which is mailed annually to m embers and i s on the SCAN website, contains essential in formation about using the SCAN health care system. It includes information regarding how to change doctors, get a referral to a specialist, how to get care if the m ember is out of area and needs emergency help, and what services can be accessed w ithout a referral. The Provider Directory, which is mailed to every SCAN mem ber and is on our website, contains information on languages other than Eng lish, spoken by providers i n the SCAN network. SCAN's Personal Assistance Line (PAL) is a concierge-like service that SCAN offers to help dual eligible patie nts navi gate provi der networks. Mem bers are paired up with own "PAL", who unde rstands their unique needs for language, types of co mmunication med ical care, and services. PAL s members to assist them taff reach es out to in finding ph ysicians in their area who speak their preferred l anguage and educates dual e ligible m embers about the fre e language interpreter benefit. The PAL staff is available 8am-8pm, 7 days per week to answer SCAN Health Plan 66 questions or help mem bers navigate thei r benefits. For afte r-hours, non-urgent health car e questions, memb ers can call our Nurse Advi ce line, SCAN On-Call, which is available 24 hours a day, 7 days a week and has staff that speak m ultiple languages. Registered nurses help members decide if and where to seek care, answer routine questions about sym ptoms, medications and prevention, and send a report to SCAN of any patient that was advised t o go to an Em ergency room so that we can follow up. Section 5.3: Education and Outreach Question 5.3.1: Describe how you will ensure e ffective communication in a range of formats with beneficiaries. SCAN has a strong history of comm unicating with mem bers who are frail and disabled and who ha ve lim ited health lite racy, and we tailor our unications communications to meet our m embers' needs. The types of comm include (1) telephone contact with the PA L Unit, (2) letters, (3) the SCAN Club Newsletter and other inform ational mate rials directed to memb ers and their families, (4) the SCAN website, and (5) audio formats. For telephone contact, call waiti ng times are m onitored and SCAN specifically avoids the use of automated response or telephone trees for incom ing calls, as memb ers have indicat ed these mechanisms are di fficult for them to use, due to hearing, dexterity, and audio processing impairments. SCAN Health Plan 67 As discussed in above sections, SCAN been designed to ensure ease of reading. 's printed material standards have For exam ple, the use of contrasting colors, sans serif font type, and increas ed use of white space in the page layout have been shown to assist readers. All written co mmunications meet CMS standards of 6t h grade reading level and 14-point font size. These standards apply to letters and printed materials and newsletters. SCAN has also developed an extensive website, for members or family who use computers. The website contains useful resources, such as community resource information, inform ation about advance care planning, and t ools t o make doctor visits more succes sful. The extensiv e Healthwise(R) Knowledgebase is a bers understand their conditi ons, compendium of healthcare topics to help mem know when to seek care, and preventive car e tips. All content is in E nglish and Spanish. If m embers prefer not to use written materials, audio m aterials can be prepared by the PAL Unit. As an exampl e, a memb er who speaks a non-threshold language, such as Arm enian, and doesn't want printed materi als, can have a translator in person at a medical site, or by telephone, or have a translator record a response to a question, which is then sent to the member on a tape or CD. Question 5.3.2: Explain how your organization cu rrently meets the linguistic and cultural needs to communicate wit h c onsumers/beneficiaries in their own language, and any pending improvements in that capability. SCAN Health Plan 68 Member-informing documents, including Evidence of Coverage documents, provider directories, and letters required by CMS or by regulation, are provided for 2012 in English and Spanish throughout California, a nd additionally Chinese and Vietnamese in Northern California. On an annual basis, per CMS regulations, SCAN determines its language threshold by reviewi ng census data. If more than 5 percent of the population that resides in a service area speaks a language other than English, materials will be translated into that language. For languages that do not meet the threshold, SCAN is able to through the use of interpreter services. SCAN also provides free medical translation serv ices to memb ers an d respond to a speci fic mem ber question providers, in the offi ce or by phone 24 h ours a day, seven days per week. SCAN contracts with several large translation services to tran slate materials, and provide translation services, including "Translation Plus" and other vendors. Sign language interpretation is also provide d at no c ost. Arrangem ents for all the se types of translations are made by the PAL Unit. SCAN has developed a pocket-sized "I SPEAK" interpreter card that advises members and providers about the availability of free language interpretation services. Th is year, additional education efforts are planned to remind members of the availability of these services. SCAN annually conducts a Dual Elig ible Group Needs Assessment (GNA) , in accordance with DHCS co ntract requirements. The scope of the GNA is to SCAN Health Plan 69 identify needs of dual eligib le members, availability of health education materials, cultural and linguistic progra ms, and any gaps i n service, towards the goal of improving health outcom es in this popul ation. The GNA includes a dem ographic profile of the popula tion, and reviews the disease prevalence, health status and utilization of health care a nd health education. The st udy also assesses the cultural and linguistic needs of the m embers, identified health disparit ies, and any gaps in services. Recommendations are made based on each year's GNA results. The 2011 GNA findings indicated that dual eligible members were not broadly a ware of the interpreter services available to them, and were also not as familiar with health education materi als. Moreover, m any of the mem bers preferred to have a convers ation about healthy behavior s as opposed to receiving printed materials. As a result, we enhanc ed our efforts t o let members know about the interpreter services, including sending a mailing to all dual eligible members of the "I SPEAK" wall et card, reminders at the end of each memb er call and articles in the SCAN Club Newsletter to members. More research will be undertaken about how to make mem bers aware of health education materials, and to develop alternate channels for disseminating health education verbally. Question 5.3.3 : Certify that you will comply with rigorous requirements established by DHCS and provide the following as part of the Readiness Review: o A detailed operational plan for beneficiary outreach and communication. o An explanation of the different mode s of communication for beneficiaries' visual, audio, and linguistic needs. SCAN Health Plan 70 o An explanation of your approach to educate counselors and providers to explain the benefit package to beneficiaries in a way they can understand. SCAN Health Plan certifies that we requirements. Section 5.4: Stakeholder Input Question 5.4.1 : Discuss the l ocal stakeholde r engagement plan and timeline during 2012 project development/implementation phase, including any stakeholder meetings that have been held during development of the Application. SCAN developed a stakeholder engageme nt strategy in preparation for the 2012 annual election period. Stakeholders include dual eligible mem participating in these discussions unity agencies, will com ply with all of the above bers, fam ily and caregivers, comm contractors, LTSS provi ders, and contr acted medical and behavioral health providers. Planning and prepar ation for this State co ntract have been t aking place since 2011. As part of this process, SCAN has communicat ed with several health plans to assess their capabilities to serv e dually eligible aged and disabled members and whether a partnership might be feasible. We have also reached out to all the MSSP provi ders in each county Demonstration to discuss coordination of in which SCAN is applying for the the LTSS benefit. We have received numerous letters of support for working t ogether to ensure continuity of care and a seamless transition a s the Demonstration goe s into effect. See letters attached at Appendix 8. SCAN Health Plan 71 SCAN has also sought input from our mem bers in these discussions. In addition to engaging our Community Advisory Committee and conducting member forums (described below), SCAN is conveni ng focus groups of FFS dual eligibles. These groups will play an integral ro le in gauging benefi ciary preferences regarding the network and lo cation of providers, determ ining which benefits this population believes are m communication methods. SCAN intends to em ploy our regular means of stakeholder engagement, which have proven effectiv e in assessing m embers' needs and preferences. We also plan to engage additi onal focus groups as the need arises. The key means of stakeholder engagement are: o Community Advisory Committee o Senior Advisory Committee o Member and Community Advisory Committee o Member Straight Talks Community Advisory Co mmittee: The Comm unity Advisory Co mmittee is comprised of dual eligible m embers and one provi der from SCAN's in-hom e and community-based services network. Th e Co mmittee meets quarterly, with two meetings held in English, and two meetings held in Spanish. Members play an integral role in developing and im proving upon di fferent programs. For exam ple, SCAN Health Plan 72 ost im portant, customer service, and preferred the Co mmittee is often asked to review clarity of message, and appearance. In solicited on how SCAN could im articles and brochures for readability, another meeting, mem ber feedback was embers get prove qua lity by assuring that m necessary tests and screenings. When SCAN rolled out our Care Transitions program--which assists mem bers in succe ssfully transferring from hospital to home or from hospital to skilled nursi ng facility--Co mmittee members provided important suggestions about how to explain and present the program. Senior Advisory Co mmittee: The Senior Advisory Co mmittee, also composed of SCAN mem bers, includes both M edicare-only mem bers and dual eligible members, and a contracted provi der. SCAN's CEO serves as an ex officio Committee mem ber. Sim ilar to the Co Committee provides feedback on mem programs, and benefits. Member and Comm unity Advisory Committ ee: In 2011, SC AN convened a Member and Community Advisory Committee to strengthen, monitor, and improve care coordination as this new system of ca re for duals is launched. This group has strategic representation from diverse cons tituency areas, includi ng men tal health, community services, long-term care, car egiver services, and cultural needs. Area Agencies on Agi ng, dual eligible me mbers and famil y members are also mmunity Advisory Committee, this ber needs, co mmunication vehicles, represented on the board and participate in these discussions. Going forward, the SCAN Health Plan 73 Committee will be expanded to include subs tance use services, independent living center services, CBAS centers, and additional health plan members and consumers. Member Forum s: Each fall, SCAN executives travel throughout SCAN's service ar ea to meet with memb ers, th eir caregivers, and potential members at "Straight Talk" events. During these meetings, the executives explain new benefits, provide attendees with an unde rstanding of the dire ction of t he organization, and answer questions. St raight Talks serve as an im portant forum for SCAN to better understand members' needs, and for members to ask any questions about SCAN or about their health care in general. In 2011, over 11,000 members attended a total of 29 sessions, hosted in 21 locations in 9 counties in California and Arizona. Question 5.4.2 : Discuss the stakeholder engageme nt plan t hroughout the threeyear Demonstration. During the three-year demonstratio n, SCAN leadership will co nsult regularly with key stockhol ders to seek continuous qualit y im provement in t he program f or the duals. We wi ll establish regular face-to-face quarterly meetings with our stakeholder advisory comm ittees, aug mented by teleconferences as the need arises. Meetings with SCAN contracted providers will occur on average twice each year through the form at of our Joint Operating Committees (JOCs). In addition, when a unique need is identified, SCAN will conduct targeted outreach to additional community agencies and advocacy organizations to seek their insight on the needs of a partic ular population. Th ese entities include the Center for Health SCAN Health Plan 74 Care Rights, the Disability Rights Lega l Center at Loyola Law School, and the Health Insurance Counseling and Advocacy Program. eaningfully involving Question 5.4.3 : Identify and describe the method for m external stakeholders in the de velopment and ongoing operat ions of the program. Meaningfully means that inte grating entities, at a minimum, should develop a process f or gathering and incorporat ing ongoi ng feedback from external stakeholders on program operations, bene fits, access to services, adequacy of grievance processes, and other consumer protections. SCAN is actively working in the co from key external stakeholders. Si mmunity to solicit meaningful input he Duals nce the announcement of t Demonstration, SCAN has organized and he ld several critical meetings with our Member and Co mmunity Advisory Committ ee to solicit advice on the program 's direction. That input has figured prom inently in our comments on t he Framework and the RFS. The Advisory Co mmittee includes mem bers representing specific stakeholder areas including Ci ty/County Se nior Services (AAA), Mental Health, Disability Services-Independent Living, Long-term Care Caregiver Services, Community Service, Cultural Needs, Du al M embers an d Du al F amily me mbers. SCAN is co mmitting to a qua rterly schedule of fa ce-to-face Advisory Co mmittee meetings, augmented by phone conferences. Another example of m eaningfully seeking community input has occurred in San Diego. SCAN is a mem ber of the Du als Demonstration Stakeholder Advisory Committee organized by San Diego Co unty's Healthy San Diego stakeholders and the Aging and Inde pendent Services Depa rtment (AIS). The group held its first SCAN Health Plan 75 organizational meeting in February. The committee includes all of the San Diego County Managed Care plans responding to the RFS a nd all of the local LTSS providers. Also participating are consum er representatives including the Consumer Center for Health Education and Advocacy , County In-Home Supportive Services (IHSS), County Behavioral Health Services, Program of All-Inclusive Care for the Elderly (PACE), Co mmunity Based Adult United Domestic Workers (UDW), Hosp Services (CBAS), Senior Alliance , ital Association of San Diego and es (ADRC), a SNF Imperial County, Community Clinics, AIS Aging Servic representative, at least three dual eligib le beneficiaries, the San Diego Regional Center, Access to Independence, and the IHSS Public Authority. In counties where similar county-inspired stakeholder invol vement groups are available, SCAN will be an active and willing participant. In develop, we will create co Advisory Committee model. Section 5.5: Enrollment Process Question 5.5.1 : Explain how you envision enroll ment start ing i n 2013 and being phased in over the course of the year. SCAN support s the Departm ent's proposa l to use an opt-out or "passi ve" enrollment process coordi nated with Medicare's Annul Enrollment Period, counties where this structure does not unty-specific Advisory Comm ittees following our beginning in October 2012. SCAN expects that beneficiar ies will be assigned to a Duals Demonstration plan containing both Medicare and Medi-Cal benefits plan in SCAN Health Plan 76 their county of residence. Th e State m ight consi der "intell igent assignm ent" of individuals based on the level of addit ional benefits that plans offer. However, this will work only if payments for individual patients ar e risk-adjusted to avoid adverse selection. Individuals will then have the opportunity to opt out of the Medicare porti on of their assignm ent a nd instead choose a Medicare Advantage plan or traditional Medicare. If the Duals Dem onstration follows th e example o f the SPD program, the State would wait to enroll in dividual beneficiaries until th e m onth of their birth, thereby providing a natural requiring a general January phase-in period tha t will be m ore efficient than 1 start date for all dua ls. SCAN has automated enrollment cap ability that is scalable in order to accommodate numerous transactions at once, and so we do not an ticipate problems connected with the first time enrollment of a populati on this size; however, phasing t he enroll ment will help to ensure that plans can p roperly coordinate care for all newly-enrolled duals from the start. SCAN is encouraged that the State is pursuing an enrollment lock-in, in which beneficiaries must remain enrolled with their selected health plan for at least six months in order to bring stability to the new program . However, the State an d health plans must be prepar ed for the possibility that CMS may reject the lock-in proposal as being too restrictive of patient choice. SCAN Health Plan 77 In term s of enrol lment process, SCAN envisions com enrollment eligibility data from DHCS to well as monthly reconciliation files. munication of SCAN via daily HIPAA 8 34 files, as Question 5.5.2 : Describe how your organization will apply lessons learned from the enrollment of SPDs into Medi-Cal managed care. Important lessons learned from the SPD transition are the need for im proved communication with potentia l enrollees and more thorough preparation and information regarding the enrollees' curre nt health conditi on--including pendi ng critical medical procedures that could be interrupted by a hasty transition to a new plan or network. Following t he SPD transition, l egislative hearings highli ghted cases of indivi duals who were scheduled for t ransplants or who needed highl y critical services, such as insulin, whose care was interrupted by a switch to a MediCal managed care plan. While these individuals represent a small percentage of the target population, special attention m ust be focused on ident ifying crit ical cases early in the transition process and delayi ng such transitions until the receiving plan is prepared to immediately and seamlessly deliver the needed care. In addition, the SPD transition experi ence showed that the information provided to those individuals being trans itioned must be far m ore user-friendly. SCAN has standing review pa nels com posed of pl an m embers to m ake sure that published materials are appr opriate for the plan mem bership. A sim ilar system SCAN Health Plan 78 should be used to develop the materi Demonstration plan enrollees. als that will be provided to potential Finally, enrolling individuals based on th eir birth m onth was a wise choice for the SPD popul ation and we believe it Demonstration. Question 5.5.3: Describe what your organizati on needs to know from DHCS about administrative and network issues that w ill need to be addressed before the pilot programs begin enrollment. The following issues m ust be addresse d prior to the start of the Duals Demonstration: o How will reimbursement levels be set? o What will be the LTSS network adequacy standards? o How will issues in the readiness review be resolved? o How will data be formatted and transferred? o Will there be "intelligent assignment" of beneficiaries and, if so, what form will it take? Section 5.6: Appeals and Grievances Question 5.6.1 : Certify that your organization will be in compliance with the appeals and grievances processes for both beneficiaries and pr oviders described in the forthcoming Demonstration Proposal and Federal-State MOU. SCAN has experience and is curren tly in co mpliance with both Medicare and Medi-Cal provider appeals and grie vance processes (see Appendix 12 for t he would also work well for the Duals SCAN Health Plan 79 list of appeals and grievances policies currently in force) . SCAN Health Plan certifies that we will co mply with the appeals and grievances processes established under the Federal-State MOU. Section 6: Organizational Capacity Question 6.1 : Describe the guiding principles of the organi zation and record of performance in delivery services to dual eligibles that demonstrate an understanding of the needs of the community or population. SCAN is guided by our m ission to fi nd innovati ve ways to enhance our members' ability to manage th eir health and to continue to control where and how they live. SCAN's philosophy of care em phasizes a holistic approach to meeting members' physical, m ental, social, and sp iritual needs. SCAN has 35 years of experience developing pro cesses and prot ocols and maintaining an orga nizational structure that furthers the goals of m anaging appropriate utilization of services and improving clinical and quality of life outcomes. Since our founding, we have worked to understand the unique needs of the duals population. We have established strong comm unity partnerships, such as with Meals on Whe els, ADHC/CBAS cente rs, and ot her agencies, and over the years we have learned from these comm unity-level organizations and applied e knowledge of the dual eligibl e populati on to enhance our person-centered car management m odel. As described in Sec tion 1, SCAN has a strong record of performance in working with the duals population, including high quality and SCAN Health Plan 80 patient satisfaction ratings, and a very high percentage of NFLOC-qualified individuals who have been able to remain in their homes rather than residing in an institutional setting. Question 6.2: Provide a current organizational chart with names of key leaders. See attached Appendix 13. Question 6.3 : Describe how the proposed key staff members have relevant skills and leadership ability to successfully carry out the project. Collectively, SCAN's key staff me experience managing the health and we mbers have hundreds of years of ll-being of at-risk populations. SCAN's Chief Medical Officer, Dr. Tim Schwab, has been with SCAN for 24 years and is recognized nationally as an expert on geri atric medicine and the establishment of integrated care systems . Ot her memb ers of SCAN' s lead ership team are masterslevel social workers or hol d doctorate degrees in public health and health informatics. Staff members' breadth of experience makes them keenly aware of the challenges facing the duals population a nd adept at dealing with issue s related to patient-centric, integrated ca re. We have attach ed additional details on our team 's skills and expertise at Appendix 14. Question 6.4: Provide a resume of the Duals Demonstration Project Manager. Up to this point, Dr. Schwab has spearheaded the Du als Demons tration project. SCAN will create a new senior-lev el management position to assume th e SCAN Health Plan 81 new duals business unit described in s attached at Appendix 15. ection 6.5. See Dr. Schwab's resume Question 6.5 : Describe the governance, organiza tional and structural functions that will be in place to implement, monitor, and operate the Demonstration. To facilitate the creation and growth of the structure needed to operate the Duals Dem onstration, SCAN will crea te a new business unit within the organization. This "Duals Operations Unit" will be solely responsible for program implementation and for ongo ing management and oversig ht. The unit will be led by a direct report of the Chief Operatin g Officer. The Unit's responsibilities will include ensuring a sm ooth, successful im plementation of the program, as well as its ongoing management. To ensure that SCAN's duals m embership is managed appropriately and effectively, there will be direct responsib ility within the Duals Operations Unit for several key functions. These includ e: Utilization Managem ent, Quality Management, Medical Management, Grieva nces and Appeals, Case M anagement, Member Services/PAL Se rvices, Beh avioral Health , an d commu nity-based mmunity who will assist be neficiaries with member advocates (staff in the co membership, benefi ts and enrollm ent support, a nd provide ongoi ng mem ber support). In addition, SCAN will de ploy a dedicated com pliance specialist responsible for overseeing all regulations Duals Demonstration. SCAN Health Plan and com pliance activity related to the 82 There are several departmen ts within SCAN that will provide shared services to the Duals Operations Unit. These departments include: Enrollment an d Reconciliation, Claim s, and Provider Se rvices. While we intend to use the infrastructure, processes, and some staff members within the se departments, there will also be dedicated resources specifically assigned to the Duals Operations Unit. The Duals Operations m anager will have oversight responsibility for shared services, and will work closely with the m anagement team o f each dep artment to ensure that all activities related to the Demonstration are being executed according to all applicable protocols and regulati ons. In addition, a num ber of corporate departments will provide adm inistrative s upport to the Duals Operations Unit. These include: Marketing, Com pliance, Finance, HR/Payroll, Facilities, and Network/Provider Management. These depa rtments have existing adm inistrative support protocols in place with other bu siness units to provide the needed supplemental support. These procedures w ill be deployed for the Duals Operations Unit. In addition to m onitoring the progr ess of implem entation, the Chief Operating Officer will also provide frequ ent status updates to the SCAN Executive Team, Board of Directions, and Quality Committee. Section 6.2: Operational Plan Question 6.2.1: Provide a preliminary operational plan that includes a draft work plan showing how it plans to implement in 2013 and ramp up in the first year. SCAN Health Plan 83 In anticipation of a January 1, 2013 implementation start date, SCAN has begun developing an implementation work plan in accordance with CMS guidance and the DHCS RFS timelines (see draft work plan, Appendix 16). SCAN has wellestablished, scalable system s and proce sses in place to accomm odate membership growth and to conti nue to provide excep tional service to our mem bers. We also have extensive experience wit h incorpora ting new product li nes into our existing organization. SCAN will be creating ongoing structure, support, and accountability for the Duals Dem onstration business model, and will be leveraging our knowledge and processes for a successful de ployment of the Duals Demonstration. In addition, we will consider utilizing e with the implementation. Key components of the proposed operational plan include: o Impact Assessment : One of the first activities in the work plan will be to conduct a detailed business impact assessment to identify additional needs and requirements to support t he Duals Demonstration. This assessment will review logistical com ponents such as IT infrastructure, staffi ng models and staffing ra tios, and facility space. In services that will be provided by addition, shared and ad ministrative SCAN's cen tral departments will be xternal expertise and resources to assist assessed, including Enrollment and Reconciliation, Claim s, and Provider Services. Anticipated transaction vol ume in th ese dep artments will be SCAN Health Plan 84 carefully analyzed an d staffing and wo rkflow projections will be develo ped to coincide with the mem bership in crease expected throughout 2013 and beyond. o Business Requirements: Another critical activity within the implementation work plan will be to finalize the co mplete set of business require ments needed to support t he expanded duals po pulation, from IT system s to staff training to busi ness proce ss enhancements. The results of this activity will determine how SCAN can exp and current capabilities to address all current and expected needs of the Duals Demonstration business. o Staffing: In conjunction with the Duals Operations unit, SCAN is developing a staffi ng plan. Within t his plan, we have developed st affing requirements based on our prelim inary estimates of membership, as well as on the expected increase in membership volume over the course of 2013 and beyond. Once SCAN receives notification of our participation in the Duals Demonstration project, we will begin staffing the unit with its leadership positions. It is expected that we will begin hiring for the Duals Operations Unit support personnel in May 2012, membership increases. o Contracting: SCAN will begin meeting with HCBS and county agencies to discuss partnerships, operational procedures, and contract negotiations. SCAN Health Plan 85 and will c ontinue to add staff as o Training: SCAN will provide m ulti-layered tr aining for its staff, including education on the Duals Dem onstration, the special needs of these memb ers, and how we can best care for them. Training curricula will be developed and will be targeted based on the em Demonstration. o Education and Outreach : SCAN has a su ccessful track record with outreach activities that provide health info rmation and benefit updates to our ployees' level of par ticipation in the members, their famil ies, and community and county partners. As part of the implementation work plan, staff will structure a calendar of comm unity events. For providers, co mmunications regarding t he Duals Dem onstration will be communicated via bi-annual Joint Operations Committees (JOCs). o Enrollment: The wo rk plan aligns Medicare Advantage enrollment period activities with the Duals Dem onstration activities to be as effective and efficient as possible. This incl udes de veloping pla n benefit packages and consistent brand marketi ng materials that will be periods. o Beneficiary On-boarding: SCAN intends to provide an exceptional, personal beneficiary on-boarding experience, similar to the process currently in place. We will conduct beneficiary meetings in the community to introduce them to their member advocates, as well as to provide assistance and education on SCAN Health Plan 86 used during enrollment topics. The on-boarding will also in clude providing guidance on PCP and group selections, conducting health assessments, identifying special needs, coordinating special case managem ent requirements, and providing ongoing education for such topics as Part D networks. All of the work plan activ ity prepares SCAN for the site readiness reviews. During and after the site readi ness reviews with CMS and the State of California, SCAN will assess the findings of the revi ews in an effort to c ontinuously improve. SCAN intends to work very closely with the State to propose additional solutions that will be advantag eous for our benefici aries, the State of California, CMS, and SCAN. Question 6.2.2: Provide roles and responsibilities of key partners. SCAN's partners in im plementation of the Demonstration include (1) health care providers, (2) county departments, services agencies . SCAN's contracted comprehensive medical care described County departm ents--specifically, Area and (3) hom e and community-based benefits, form ularies, and provider health care providers carry out the under Network Adequacy in Section 7. Agencies on Aging, Departments of Mental Health, and the State Department of Rehabilitation offices--partner with SCAN to provi de HCBS, mental health se rvices, and rehabil itation services for individuals who may seek retraining for work. These relationships and SCAN Health Plan 87 responsibilities, including scope of serv ice, use of comm on assessment form s, referral methods and paymen t, will be codified in Mem oranda of Understanding (MOUs). A wide array of HCBS providers in each county will partner with SCAN to serve the dual eligible population. Some of these providers will be accessed by referral (e.g., caregiver agencies, housing facilities, Meals on Wheels), while others wil l be based on cont racts (e.g., transport ation, personal care, telephone emergency response systems). These various types of partners will meet at least quarterly with SCAN Dual Demonstration leadership through cha nnels that include JOCs, Mem ber and Community Advisory Comm ittees, and as small group m eetings for pl anning and monitoring. Question 6.2.3: Provide a tim eline of m ajor milestones and dates for successfully executing the operational plan. Please see Appendix 16. Question 6.2.4 : Certify that the Applicant will report monthly on the progress made toward implementation of the timeline. These reports will be posted publicly. SCAN Health Plan certifies that we will comply with the above requirement. Section 7: Network Adequacy Question 7.1 : Describe how your organization network is adequate for your specific enrollees. will ensure that your provider SCAN Health Plan 88 To ensure our provi der networks are ad equate to meet the needs of current and future enrollees, SCAN uses network provider data, enr ollee residence d ata, Quest Analytics software, and CMS crite ria that include county level m inimum numbers of providers and time/distance standards. Ninety percent of enrollees must have access to at least one provi der with in the time/distance st andard for that ria can be m odified to m eet DHCS provider t ype and county. These crite requirements, including but not limited to adding provider types such a s long-term care facilities and adding Medi-Cal eligible and enrollee residence data. SCAN reports and analyzes network ad equacy for all c ounties and product lines at least semi-an nually. If deficiencies are identified, remediation includes but is not lim ited to contracting directly w ith appropriate provi ders, working with delegated provi der groups to contract with or add a ensuring accuracy of provider types an ppropriate providers, and d addresses in our system. SCAN also works with provi der groups t o arrange for specialty care outside of our provi der network when network providers are unavaila ble or inadequate to meet enrollees' medical needs. In addition, SCAN ensures enrollee linguistic needs are met by co mparing enrollee and PCP languages and taking a ppropriate action, including but not limited to offering translation services 24 hours a day, 7 days a week, working with delegated provi der groups t o contract provi ders who speak and/or write the SCAN Health Plan 89 required languages, and reaching out to enro llees to assist them with finding PCPs in their area who speak their native language. Question 7.2 : Describe the methodologies you plan to use (capitation, Medicare rates, extra payments for care coordination, etc.) to pay providers. For the Duals Demonstration, SCAN w ill continue to use our contracted provider network that serves our existi ng duals population. These providers are paid based on a mix of capitation, Medicar e r ates, and case ra tes. All of our organized medical groups are paid on a cap itation basis to coordinate care and act as the medical home in concert with SCAN's car e management programs. Most of our hospitals and ancillary providers a re paid on an FFS basis at Medicare- allowable rates and, in som e instances, cas e rates for co mmon procedures such as open heart surgery or transpl ants. Some provider contracts contain additional funding for care coordination in support of demonstrated quality care outcomes. In addition, SCAN offers incentive program s for all interested providers, which offe r higher com pensation for demonstrated qua lity outco mes (i.e., HEDIS measures) and could be adjusted to meet the specifi c goals of the Duals Dem onstration. For example, as part of our End Stage Renal Disease (ESRD) C-SNP, we established a revenue sharing program to incentivize nephrologists to meet the quality measures established for the program , whereby th ey dem onstrate adherence to quality protocols. All such incentives would de pend on the rates to be paid under the Demonstration. SCAN Health Plan 90 Question 7.3 : Describe how your organizati on w ould encourage providers who currently do not accept Medi-Cal to participate in the Demonstration project. Many providers do not accept Medi-Cal be cause t hey are fr ustrated by the disjointed nature of Medi-Cal benef its and covered services. To encourage participation, SCAN will educate providers about the benefits of participating in the Duals Demonstration, including: o The stream lining that would come with participation in the Duals Demonstration, m inimizing the adm inistrative burden on their practice as compared with traditional Medi-Cal, and m inimizing coverage issues for beneficiaries (e.g., carrying two m embership cards, being referred to a nonparticipating provider); o The ability of non-Medi-Cal providers to increase their current patient base under the Demonstration; o The real opport unities to im prove patient s' overall health afforded by t he Demonstration's coordinated approach; Some providers m ay choose not t o participate because of the rates paid by Medi-Cal. To enco urage participation in the Dem onstration by t hese providers, SCAN wi ll educate them ab out SCAN's D-SNP experience, dem onstrating reasonable payment levels when coordi nating care under Medicare and Medi-Cal funding. While we cannot assure or Demonstration will exceed SCAN Health Plan Medi-Cal guarantee that the rates under the rates, since the financing of the 91 Demonstration is to be finaliz ed, we can say that our current experience in the DSNP space proves that revenue is higher and is "prepaid", with no billing required. Question 7.4 : Descr ibe how you will work with providers to ensure accessibility for beneficiaries with various disabilities. SCAN performs pre-contractual and ongoing Facility Site Reviews for PCPs serving dual eligibles, in accordance with the DHMC-approved tool to assure access for those with disa bilities. Thro ugh these reviews, SCAN educates providers about accessibility requirements and then ensures that providers are maintaining these standards through additional visits. Under the Duals Demonstration, SCAN will expand these site visits to include ancillary providers beyond PCPs. In addition, SCAN be lieves it is very im portant to ensure that our providers understand the accessibility c hallenges faced by the elderly and the disabled. To educate providers and their staff about these challenges, SCAN provides a program called "Trading Ages" in which participants experience the onset of disabilities and diminished faculties and learn first-hand what it is like to feel like the patients they treat. Additional ways that SCAN prom otes patient accessibility with providers include: o Through provi ders, SCAN distributes appropriate, easy-to-underst and patient information in formats that include Braille, large-print, and audio. SCAN Health Plan 92 o SCAN provides transportation to provider offices for our frai l and disabled members, as well as a personal care escort for NFLOC-qualified members o SCAN provides a TTY telephone line and si gn language services on-si te at the physician office for members who are hearing-impaired. SCAN will continue these efforts under the Duals Demonstration. Question 7.5: Describe your plan to engage with providers and encourage them to join your care net work, to the ext ent those providers are workin g with the Demonstration population and are not in the network. SCAN will work with our contract communities to assess continuity of car ed provider groups in the local e needs and will expand our provider network as appropri ate. To encourage pr oviders t o join our network, SCAN will educate providers about the im portance of continuity of care for the member to ensure high quality care and the best possi ble outcomes, as well as the im portance of maintaining the mem ber's relationship with their current care providers. SCAN will educate providers about the support caring for these patients through the that they would have from SCAN in coordinated care approach under t he Demonstration and the benefit to patients inherent in receivi ng coordi nated care. Finally, we will em phasize the ease of ad ministration that comes with joining our provider network, particularly as com pared to navigating bot h the Medicare and Medi-Cal payment systems. SCAN Health Plan 93 Question 7.6 : Describe proposed subc ontract arrangements (e.g., contracted provider network, pharmacy benefits man agement, etc.) in support of the goal of integrated delivery. Under the Duals Dem onstration, SCAN will continue to work with our contracted provider network t hat currently serves our dual eligible beneficiaries . SCAN's contracts with these provider groups are i n full compliance with Federal and State requirements. To support the care needs of an expanded duals membership, we will expand our existi ng contractual relationshi ps a nd develop new ones to the extent needed to meet d emand for medical care, behavioral health and LTSS. SCAN also intends to conti nue working with our currently-contracted pharmacy benefits ma nager, ExpressScripts, t o de liver pharm acy management services to our current duals and Demonstration. As payment rates are publishe d, subcontracting arrangements with ancillary providers will be nego tiated. These contractors may in clude vision, dental, hearing aids and transportation. Question 7.7 : Certify that the goal of integrated delivery of benefits for enrolled beneficiaries will not be weakened by sub-contractual relationships of th e Applicant. SCAN Health Plan certifies to the above. Medicare standards for medical Question 7.8 : Certify that the Plan will meet services and prescription drugs and Medi -Cal standards for long-term care networks and during readiness review will demonstrate this network of providers is sufficient in number, mix, and geographic distribution to meet the needs of the anticipated number of enrollees in the service area. SCAN Health Plan 94 the expanded duals population under the SCAN Health Plan certifies that requirements. we will com ply with the above Question 7.9 : Certify that the Plan will meet all Medicare Part D requirements (e.g., benefits, network adequacy), and submit formularies and prescription drug event data. SCAN Health Plan certifies that requirements. Section 7.2: Technology Question 7.2.1 : Describe how your organization is currently utilizing technology in providing quality care, inclu ding efforts of providers in your network to achieve the federal "meaningful use" health information technology (HIT) standards. SCAN's contracted provider network of medical groups has been focused on the im portance of moving thei r physician offices toward meeting m eaningful use requirements. Despite encountering cha llenges with the process and obtaini ng we will com ply with the above incentive payments, the provi der network ha s not been deter red from such efforts. Virtually all of SCAN's providers ha ve either implement ed electronic health record (EHR) system s or are in the pro cess of im plementing them . As a health plan, SCAN seeks to support our providers in EHR adoption. Whenever feasible, providers and SCAN share data through secure portals, electronic data interface (EDI), and direct shared access of system s. For exam ple, SCAN st aff are users of certain provide r systems through which SCAN case managers have access to r eal-time patient care inform ation, which supports case management and ut ilization management seamless quality care. SCAN Health Plan 95 activities. The shared data enables In addition, all SCAN case manageme nt program s use th e same software, McKesson's CareEn hanced Cl inical Manage ment Software (CCMS), to assess, monitor, and report on case management ac tivities. The system can be used on a laptop when visits t o the m ember's home are made and it can generate care plans, member letters and assessment summ aries that are sent to provi ders. SCAN leverages Pharm MD's MedP ro software platform for its MTM Program , which reviews mem ber medication profiles and id entifies drug therapy problems (i.e. therapeutic duplication, gaps in thera py, drug-drug interactions) by utilizing evidence-based medicine, national gui deline standards and proprietary rule sets to identify potential interventions and re pharmacist to intervene on issues. SCAN has experience with several member m onitoring de vices. SCAN duces the time to imp act by a SCAN participated in a test of an Int el touc h screen product that allowed mem ber/case manager comm unication. Currently, mem bers in the CHF Diseas e Managem ent program are testing the utility of Bluetooth scales that report their daily weights to their case manageme nt. Since weight gain often si gnals dangerous fluid retention in CHF p atients, the alert can trigger a quick response by th e case manager and physician. Question 7.2.2: Describe how your organization intends to utilize care technology in the duals Demonstration for beneficia ries at very high-ri sk of nursing home admission ( such as telehealth , remote health vital s and activity monitoring, care management technologies, medication compliance monitoring, etc.) SCAN Health Plan 96 SCAN uses a broad set of technology tools throughout t he care delivery process to ensure quality, identify indivi duals for intervention, trend and identify opportunities for quality improvem ent, perform case managem ent, and apply clinical criteria to ensure appropriate utili zation. Due in no small part to our use of health IT tools, SCAN has successfully kept 98 percent of NFLOC m embers in their own homes and out of institutional care. We intend to continue to enhance our care managem ent processes by leveraging our staff and technol ogy t o keep our members independent and healthy. SCAN's proprietary risk st ratification model identifies high-risk m embers by analyzing bot h the typical data el ements (e.g., diagnoses, medications, demographics), and data re garding functional and health status. Once identified as a high-risk m ember, SCAN uses sophisti cated care man agement and medication therapy management software to consis tently and appropriately manage the member's care. SCAN's case manageme nt software--McKesson's CareEnhanced Clinical Management So ftware (CCMS)--facilitates communication across case management programs and medical offices, and newly developed interfaces collect data in the field via m obile technologies. These robust capabilities have been built, tested, and revised over the l ast 10 years and offer a scalable platform to serv e SCAN's current memb ers, as well as la rge num bers of pot ential newly enrolle d SCAN Health Plan 97 duals. Our ultim ate objective is to expand this set of system s to agg regate the combined information across the spectrum of care for our members. SCAN currently use s telem onitoring to support quality care and intends to expand the use of such rem ote tool s under t he Duals Dem onstration. Our mote m onitoring scales to m embers, telemonitoring scale program provides re which interface with the case manageme nt so ftware to provide alerts to disease management nurses that enable them to addition, SCAN has developed a user inte Arizona plan, to collect data duri support mem bers' self-managem ent. In rface, currently being piloted in our o use thi s ng i n-home visits, and intends t technology under the Duals Demonstr ation. SCAN will deploy in-home onitoring monitoring technol ogies, such as blood pressure cuffs, glucose m systems, medication adherence alerts and daily. SCAN will leverag e these mobile Bluetooth scales that transmit weight technologies to collect real-tim e, actionable data on beneficiary health status in order to suppor t our goal of keeping our members out of institutional care. Question 7.2.3 : Describe how technologies will be utilized to meet information exchange and device protocol interoperability standards (if applicable). SCAN support s national and local effo rts to adopt health inform ation exchanges (HIEs) and device protocol inte roperability standards and believes that standardizing the exchange of health inform ation will help stream line car e delivery. SCAN intends to continue m oving towards the adoption of software and SCAN Health Plan 98 devices that m eet interoperability standard s in order to support providers' use of EHRs and our i ntended use of in-hom e remote m onitoring technologies. In addition, SCAN is developing a system s architecture that will ensure maxim um system flexibility by being easily adaptable to the interoperability standards as they evolve and by accomm protocols. Section 8: Monitoring and Evaluation The evaluation will examine the quality and c ost impac ts on spe cific vital Medicare and Medi caid services, includi ng the i ntegration on IHSS and ot her home-and community-based LTSS. Therefore, the Applicant must: Question 8.1: Describe your organiza tion's capacity for tracking and reporting on: o Enrollee satisfaction, self-reported health status, and access to care, o Uniform encounter data f or all cove red services, including HCBS and behavioral health services (Pa rt D requirements for reporting PDE will continue to be applied), and o Condition-specific quality measures. SCAN currently tracks and reports on numerous quality and perform metrics, including the following: a. Enrollee satisfaction, self-reported health status, and access to care SCAN conducts t he Consum er Assessm ent of Healthcare Providers and Systems (CAHPS) survey to ask our mem bers to report on and evaluate their ance odating unanti cipated requirem ents or changes in t he experiences with SCAN and their health care services. Th e CAHPS survey covers topics that are im portant to mem bers and focuses on aspects of quality that SCAN Health Plan 99 members are best qualified to assess, such as the communication skills of providers and eas e of access to health care servi ces. Mem bers are asked to report their overall ratings of al l health care, persona l doctor, specialist, and health plan. Information about mem bers' self-rated hea lth st atus is included in the survey. SCAN an nually subm its results from the CAHPS survey to CMS an d uses the results to direct ongoing improvements in SCAN's member-focused operations. SCAN also adm inisters its own Health Questionnaire (HQ) annually t o all SCAN mem bers to gather data on servi members' health. The HQ collects inform ce quality towards the im provement of ation on mem bers' self-rated health status and on mem bers' history of access to care. Reports based on the responses are generated regularly to identify any issu es that re quire attention. Information is used internally to guide the disease managem ent and complex case management programs, and is also shared with m embers' PCPs to continually i mprove the quality of care they are delivering to our members. b. Uniform encounter data for all c behavioral health services (Part D continue to be applied) SCAN has extensive experi ence co llecting data from provi ders and overed services, includi ng HCBS and requirements for re porting PDE will submitting process and outcomes data, incl uding aggregated results, regularly to the State and Federal govern ments and their contractors. SCAN has existing SCAN Health Plan 100 protocols and an infrastructure to collect, analyze, and report on uniform encounter data for all covered servi ces, including HCBS , behavioral health services, and Medicare Part D pharm acy data. SCAN accepts and subm its encounter data in standard HIPAA mandated form ats, as we ll as indust ry a nd regulator required formats. SCAN has built and actively maintains a state-of-the-art encounter data system that autom ates data processing, thereby enabling encounter dat a staff to actively analyze, research, and m onitor data subm ission rates, quality, and onitoring is completeness from provi ders a nd to regulators. This analysis and m driven by operational system reporting as well as specifically developed reports. All data received into the encounter data system is stored within one schema, ensuring consistency for various submission and research efforts. SCAN utilizes an enterprise-wide Data Warehouse (DW). The DW is a secure and reliable integrated repository of corporate information, orga nized to support analysis and report ing. Value is added by calculating and providing common business m easures. The DW is a "single source of t ruth" for cor porate information. Executives, operations personnel and analysts leve rage the DW through Busi ness Intelligence tools such as: direct queries, ad-hoc and standa Information Systems, etc. c. Condition-specific quality measures rdized reports, dashboards, Executive SCAN Health Plan 101 SCAN uses the Healthcare Effectivene ss Data and Information Set (HEDIS) tool to m easure our perform ance on important di mensions of care and service. HEDIS includes many condition-specific qua lity measures, such as quality of antidepressant m edication managem ent. SC AN annually reports resul ts from the HEDIS to CMS. In addition, SCAN continues to have a successful track record improving quality of care and quality of life for frail elderly Medicare beneficiaries. For exam ple, in 2011, SCAN performed in 90th percentile am ong Medicare D-SNPs on a wide range of HEDIS qualit y measures, including colorectal cancer screenings, glauco ma screening, and a num ber of comprehensive diabetes care measures. Question 8.2 : Describe your organi zation's ca pacity for reporting beneficiary outcomes by demographic characteristi cs ( specifically age, English proficiency, disability, ethnicity, race, gender, and sexual identity). SCAN is experienced in reporting beneficiary out comes by dem ographic characteristics. Many of the health outcome measures in SCAN's annual HEDIS report are age- or gender-specific. In ad dition, the Health Questionnaire described above includes mem bers' dem ographic char acteristics, such as age, gender, race/ethnicity, English proficiency, and disa bility measures, s uch as difficulties in Activities of Daily Living (A DLs). The da ta SCAN collects through the various surveys and data sets can be sorted and reported based on m ost of these demographic characteristics, including a ge, gender, race, ethnicity and disability. SCAN Health Plan 102 In addition, SCAN recently conducted a group needs assessment, which identifi ed the ability to sort data b ased on other de mographic characteristics (e.g., English proficiency and sexual identity) as a needed process improvement. Question 8.3 : Certify that you will wo rk to meet all DHCS evaluation and monitoring requirements, once made available. SCAN Health Plan certifies that we will comply with the above requirement. Section 9: Budget Question 9.1: Describe any infrastructu re support that c ould help facilitate integration of LTSS and behavioral hea lth services ( i.e. information exchange, capital investments and trai ning t o i ncrease accessibili ty of network providers, technical assistance, etc.). SCAN has submitted an application for a Center for Medicare and Medicaid Innovation (CMMI) Health Care Innovati million. The goal is to add comm on Challenge Grant wort h $11.212 unity h ealth workers and m obile and rem ote technologies to our current robust model of care to build a paradigm for the care of dual eligibles nationwide. If CMMI ac cepts our application, SCAN will incorporate the proposal into the California Duals Demonstration project. SCAN's proposal creates the technol ogical and hum an infrastructure to surround high-need patients w ith services that at tend to their medical needs and preserve their inde pendence. Specifi cally, SCAN's proposed Enhanced Care Management Model will improve care for the target population by: o Expanding the effectiveness of curre nt m edical and support services by adding culturally-com petent comm unity health workers to our current SCAN Health Plan 103 comprehensive care team of physic managers, and telephonic assistants; ians, nurse practitioners, case o Enhancing beneficiary comm unication across t he care continuum--from the hom e to all clinical settings --through the use of cutting-edge technology to im prove the breadth a nd timeliness of collected data and ensure that the right care is deliv beneficiary satisfaction; o With this human and technological infrastructure in place, engaging ered at the right time with high beneficiaries to assume a greater ro le in their own health by prom oting the use of primary and out-patient care i n the co mmunity, and through preventive, behavioral health, and co mmunity-based social services an d supports; and o Lowering costs through a reductio n in inpatient adm issions and readmissions, inpatient length of stay , emergency department visits, and skilled nursing facility stays, when clinically appropriate. The proposed Enhanced Care Manage ment Model is projected to serve 12,100 dual eligible benefici aries and result in $170,581, 379 of savings over three years--a 4.73:1 return on investment re beneficiaries. lative to FFS costs for dual eligible SCAN Health Plan 104 In short, SCAN will lower costs for du al eligible beneficiaries relative to FFS through better c are coordination that lo oks at e ach individual's level of need and unique situation. Moreover, this m odel will allay patient advocate concern about moving dual eligibles to health plans with little experience in caring for this complex population. SCAN Health Plan 105 List of Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 4.1 4.2 Appendix 5 5.1 5.2 Appendix 6 Appendix 7 7.1 7.2 7.3 7.4 Appendix 8 8.1 8.2 8.3 St 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12 8.13 8.14 Appendix 9 Appendix 10 10.1 Knox-Keene license SCAN Health Plan Financial Statement as of 12/31/11 per DMHC website DMHC Enforcement Actions for SCAN Health Plan Quality Indicators DHCS Quality Performance Indicators including HEDIS MA-SNP Quality Performance Requirements including HEDIS Local Stakeholder Support Response to Mandatory Qualification #12 SCAN Health Plan Member/Community Advisory Committee Charter History of Corrective Action Plans in last five years Letter of Intent to Work in Good Faith - County Letters San Diego County Department of Health and Human Services San Diego Public Authority City of Los Angeles, Department of Aging County of Los Angeles, Chief Executive Office Letters of Support Alzheimer's Association - Debra Cherry, Ph.D. Wise and Healthy Aging - Grace Cheng Braun Barnabas Senior Services - Rigo Saborio Heritage Clinic - Vatche Kelartinian, MBA Mexican American Opportunity Foundation - Elizabeth Jimenez Human Services Association MSSP - Darren Dunaway Huntington Hospital MSSP - Jane Haderlein Jewish Family Service of Los Angeles MSSP - Paul Castro Partners in Care Foundation MSSP - W. June Simmons University of Colorado - Eric Coleman, MD, MPH Florida State University - Kenneth Brummel-Smith, MD Johns Hopkins University - Chad Boult, MD, MPH, MBA Leading Age - Cheryl Phillips, MD University of Minnesota - Robert Kane, MD Comparison of SCAN Dual Eligibles vs California FFS Dual Eligibles (Study by Avalere Health, February 2012) SCAN Health Plan Model of Care Model of Care Confidentiality Request Letter SCAN Health Plan Appendix 11 11.1 11.2 11.3 11.4 Appendix 12 Appendix 13 Appendix 14 Appendix 15 Appendix 16 Evidence Based Guideline for Physicians and Case Managers Examples Case Manager - Screening and Prevention Case Manager - Depression Case Manager - Diabetes Physician Guideline - Hip Fracture Appeals & Grievances process currently in force Duals Demonstration Program Organization Chart Proposed key staff members chart Resumes for staff - Timothy Schwab, M.D. Timeline for Operational Work Plan SCAN Health Plan I I II II I IFMIIE I I I Iwlm THIS LICENSE IS NOT TRANSFERABLE OR ASSIQIABLE .FileN0.I - - IIS AS AI HEALTH CARE -ISERVICE PURSUANT TO AS AND IS AUTHORIZED TO INIBUSINESS ASIA SERVIE PLAN WITHIN THE STATE OF CALIFORNIA SUBJECT TO THE PROVISIONS I . OF SAID THE RULES OF THE COMMISSIONER 0F`c01zp0nAT10Ns ADOPTED PURSUANT THERETO, UNTIL SUCH TIIEI AS SE IIS SUSPENDED OR REVOKED BYQORWR OF THE ok IS - I THIS LI ISNISSEBD AND ONTTHE DATE APPEARING-BELWSEHH Assistant Oommi siccnet I I II II I IFMIIE I I I Iwlm SCAN HEALTH PLAN NOTES TO FINANCIAL STATEMENTS AS OF AND FOR THE TWELVE MONTHS ENDED DECEMBER 31, 2011 1. ORGANIZATION SCAN Health Plan (the "Company"), a California nonprofit public benefit corporation, is a health maintenance organization providing comprehensive medical care and specialized social services to seniors and other Medicare eligible beneficiaries in California through the use of managed care arrangements. On November 30, 1984, the Company was licensed by the State of California as a Health Care Service Plan pursuant to the Knox-Keene Act of 1975, as amended. Enrollment of participants in the Company's managed care plan began on March 1, 1985. Prior to December 31, 2007, the Company operated as a Medicare Advantage Organization ("MAO") as mentioned below, with a special waiver as a Social Health Maintenance Organization ("Social HMO") under a national demonstration program administered by the Centers for Medicare and Medicaid Services ("CMS"), an agency of the federal government, in four counties: Los Angeles, Orange, Riverside, and San Bernardino. The waiver expired on December 31, 2007. With the expiration of the aforementioned waiver, the Company continues to operate as a MAO. The Company receives substantially all of its revenue from CMS. In addition, the Company has a contract with the California Department of Health Care Services ("DHCS") to serve dually eligible and dually enrolled beneficiaries in the Medicare and Medi-Cal programs. Furthermore, the Company expanded its Medicare Advantage offerings to beneficiaries in Ventura, Kern, and San Diego counties in 2006 and 2007; San Joaquin County in 2009; and Contra Costa, Santa Clara, and San Francisco in 2010. The Company also receives grants from the State of California, local governments, and private foundations to provide in-home services for those individuals who are at risk of being institutionalized. SCAN Group is the sole corporate member of the Company, The SCAN Foundation (through December 31, 2009), and SCAN Health Plan Arizona. SCAN Health Plan Arizona is an Arizona nonprofit corporation, which in turn, is the sole corporate member of SCAN Long Term Care, an Arizona nonprofit corporation. The Company is exempt from federal and California income taxes in accordance with Internal Revenue Code ("IRC") Section 501(c)(3) and California Revenue and Taxation Code Section 23701(d), respectively. 2. REGULATORY REQUIREMENTS AND OPERATIONS Under the Knox-Keene Health Care Services Plan Act, the Company must comply with various rules and regulations, including certain tangible net equity requirements. In addition, the Company is subject to regulatory oversight by CMS, the California Department of Managed Health Care (the "Department"), and DHCS, among others. The Company is required to periodically file financial statements with regulatory agencies in accordance with various statutory accounting and reporting practices. At December 31, 2011, the Company is in compliance with the tangible net equity requirement of the Department, as the Company's required tangible net equity was $23,721 as compared to actual tangible net equity of $674,023. 3. SUMMARY OF SIGNIFICANT ACCOUNTING POLICIES Basis of Presentation -- The accompanying financial statements include the accounts of the Company and have been prepared in accordance with accounting principles generally accepted in the United States of America ("generally accepted accounting principles" or "GAAP"), including Financial Accounting -1- Standards Board ("FASB") Accounting Standards Codification ("ASC") 958, Not-for-Profit Entities. FASB ASC 958 establishes standardized external financial reporting by not-for-profit organizations. Generally accepted accounting principles require not-for-profit organizations to report information regarding their financial position and activities according to three classes of net assets: unrestricted net assets, temporarily restricted net assets, and permanently restricted net assets based on the existence or absence of donor-imposed restrictions. As of December 31, 2011, the Company had no temporarily or permanently restricted net assets. Use of Estimates -- Management uses estimates and assumptions in preparing the financial statements in accordance with generally accepted accounting principles. Those estimates and assumptions affect the reported amounts of assets and liabilities, the disclosure of contingent assets and liabilities, and the reported revenues and expenses. Actual results could vary from the estimates that were assumed in preparing the accompanying financial statements. Cash and Cash Equivalents -- Cash and cash equivalents primarily include highly liquid debt instruments purchased with a remaining maturity of three months or less, as well as cash on hand and on-demand bank deposits. Investments -- Investments are accounted for in accordance with FASB ASC 958-320, Not-for-Profit Entities-Investments-Debt and Equity Securities. Under FASB ASC 958-320, equity securities with readily determinable fair values and all investments in debt securities are reported at fair value with realized gains and losses included in Report #2: Revenue, Expenses and Net Worth. Unrealized gains and losses are included in Report #2: Revenue, Expenses and Net Worth unless the unrealized losses are deemed to be other than temporary, in which case, the losses are recorded as realized. During the twelve months ended December 31, 2011, the Company did not record any realized losses for investments deemed to be other-than-temporarily impaired. Investment securities, in general, are exposed to various risks, such as interest rate, credit, and overall market volatility. Due to the level of risk associated with certain investment securities, it is reasonably possible that changes in the values of investment securities will occur in the near term and that such changes could materially affect the amounts in Report #1-Part A: Assets. Premiums and Other Receivables -- Receivables include amounts due from third-party payors, such as government-sponsored health care programs ("Medicare" and "Medi-Cal"), premiums from employers, and amounts due from members. The Company establishes an allowance for those accounts that are estimated to have credit risk. The Company does not believe that there are significant credit risks associated with reimbursement from government-sponsored health care programs. Policies for recording receivables relating to changes in risk adjustment factors are discussed in the revenue recognition and unearned premiums section. Property and Equipment -- Property and equipment are recorded at cost. Depreciation is provided on the straight-line method over the estimated useful lives of the assets as follows: Computer equipment and software Office furniture and equipment Leasehold improvements Vehicles 3-10 years 3-10 years 3-12 years 5 years -2- Assets purchased with the use of government grant funds are considered to be the property of the government agency in accordance with the contracts between the Company and the government agency. Accordingly, these assets are expensed when purchased, and no provision for depreciation of these assets is made. For the twelve months ended December 31, 2011, the Company did not purchase any assets with government grant funds. Impairment of Long-Lived Assets -- Management reviews long-lived assets to be held and used in the Company's operations for impairment at least annually, or more frequently if circumstances indicate that the carrying amount of an asset may not be recoverable. Long-lived assets are deemed to be impaired if estimated undiscounted future cash flows are less than the carrying amount of the assets. Estimates of expected future cash flows are based on management's best estimates of anticipated operating results over the remaining useful lives of the assets. The Company measures the impairment as the amount by which the carrying amount of the asset exceeds the fair value of the asset. Management does not believe any impairment of its long-lived assets existed at December 31, 2011. Revenue Recognition and Unearned Premiums -- Generally, Medicare Advantage organizations' membership contracts with individuals are subject to an annual election period after which members are locked into the contract and can only disenroll in limited circumstances. Dually eligible and dually enrolled individuals (Medicare and Medi-Cal eligible and enrolled), however, may disenroll monthly. Employer group retiree plan membership contracts are renewed on an annual basis. Certain optional membership contracts are on a monthly basis, subject to cancellation by the individual upon 30 days' written notice. Under each of these types of membership contracts, revenues are recognized based on the estimated number of eligible members per month multiplied by the contracted monthly capitation rate, which is adjusted for member health status. Revenue is recorded in the month in which eligible members are entitled to health care services. Premiums received prior to the month earned are reported as unearned premiums in the financial statements. Certain estimates are required to record revenues and accounts receivable at net realizable value due to the nature of the membership contracts, specifically eligibility changes in the membership base. These estimates are based on actual historical adjustments to monthly capitation premiums. Inherent in these estimates is the risk that they will have to be adjusted as additional information becomes available. Such adjustments are typically identified and recorded at the point of cash application or account review. Medicare and Medi-Cal revenues are potentially subject to audit and retroactive adjustment by the respective regulatory agencies responsible for those programs. Laws and regulations governing these programs are extremely complex and subject to interpretation. As a result, there is at least a reasonable possibility that recorded estimates will change by a material amount. The Company has an arrangement with CMS for certain Medicare products, whereby periodic changes in its risk factor adjustment scores for hierarchical condition category codes ("HCC risk scores") result in changes to health plan services premium revenues. CMS uses a risk-adjustment model to determine the premium amount it pays for each member. The CMS risk-adjustment model allocates premiums paid to all MAO plans according to the health status of each beneficiary enrolled and pays more for Medicare members with higher HCC risk scores. The Company recognizes changes in receivables previously accrued when the amounts to be received become determinable, supportable, and collectibility is reasonably assured. Because the recorded revenue is based on the best estimate at the time, the actual payment received from CMS for risk adjustment reimbursement settlements may be different than the amounts initially recognized in the financial statements. -3- Hospital, Physicians, and Other Services -- Health care costs are recorded in the period when members are entitled to services. Substantially, all physician services and a majority of hospital services are provided under capitated contractual agreements, some of which include the establishment of a risk-sharing fund. The Company establishes the risk-sharing fund by retaining a portion of the providers' monthly capitation payments. Providers bear the level of financial risk specified in their respective contractual agreements if mutually agreed-upon hospital utilization goals are not achieved. The Company runs the risk with capitated contracts of delegated administrators ("DA") being unable to meet their financial obligations. The liability for certain delegated claims may be transferred to the Company in the event of DA insolvency or termination of a DA agreement. To manage this risk, the Company monitors the financial status of the DA network via analysis of the DA's quarterly financial statements, annual audited financial statements, and by conducting on-site audits. The Company has the contractual right to withhold a portion of capitation otherwise payable to the DA in the event that a DA becomes insolvent or terminates an agreement. This withhold is held in reserve by the Company to cover any potential transfer of delegated liabilities and is included in medical claims payable in Report #1- Part B: Liabilities and Net Worth. The Company also accepts hospital risk through contractual agreements other than capitation. The cost of health care services is recognized in the period in which services are provided and includes an estimate of the cost of services that have been incurred but not yet reported. The Company estimates the amount of the provision for service costs incurred but not reported ("IBNR") using standard actuarial methodologies based upon historical data, including the period between the date services are rendered and the date claims are received and paid, denied claim activity, expected medical cost inflation, seasonality patterns, and changes in membership. The estimates for service costs IBNR are made on an accrual basis and adjusted in future periods as required. Any adjustments to the prior period estimates are included in the current period. Such estimates are subject to the impact of changes in the regulatory environment and economic conditions. Given the inherent variability of such estimates, the actual liability could differ significantly from the amounts provided. The Company assesses the profitability of its Medicare and Medi-Cal contracts for providing health care services when operating results or forecasts indicate probable future losses. The Company establishes a premium deficiency liability in current operations to the extent that the sum of expected future costs, claim adjustment expenses, and maintenance costs exceeds related future premiums under contract. For purposes of determining premium deficiencies, contracts are grouped in a manner consistent with its method of acquiring, servicing, and measuring the profitability of such contracts. The Company did not record any premium deficiency reserves as of December 31, 2011. While the ultimate amount of claims and expenses is dependent on future developments, the Company believes the liability for medical claims payable, shared risk settlements, and other reserves included in medical claims payable in Report #1- Part B: Liabilities and Net Worth are reasonable estimates to cover such costs. Medical Administration Expenses -- Medical administration expenses include care management for Medicare and Medi-Cal members who meet specified criteria, quality assurance, utilization management, compliance, member services, grievances and appeals, and geriatric practice innovation. Deferred Compensation -- The Company maintains various nonqualified retirement plans that cover certain key executives. The Company accrues expenses related to these plans over the applicable vesting periods. -4- Income Taxes -- The Company is recognized as a tax-exempt entity under IRC Section 501(c)(3) and California Revenue Code Section 23701(d). Fair Value of Financial Instruments -- The carrying amounts of cash and cash equivalents, restricted cash, premiums and other receivables, and accounts payable and accrued expenses at December 31, 2011 approximate fair value because of the relatively short period of time between origination of the instruments and their expected liquidation. The fair value of investments is presented in Note 8. Recent Accounting Pronouncements -- In September 2009, the FASB amended ASC 820, Fair Value Measurements and Disclosures, for measuring the fair value of investments in certain entities that do not have a quoted market price but calculate net asset value per share or its equivalent. Equivalents to net asset value per share include net asset value per member unit or per an ownership interest in partners' capital that is entitled to a proportionate share of net assets. Such investments, sometimes referred to as alternative investments, include certain hedge funds, private equity funds, real estate funds, venture capital funds, and offshore funds. The new accounting guidance is effective for annual periods ending after December 31, 2009. The Company adopted this standard, as amended, as of December 31, 2010, noting no additional disclosure deemed necessary. In January 2010, the FASB amended ASC 820 to require new disclosures related to transfers in and out of Level I and Level II, including reasons for the transfers, and to require new disclosures related to Level III fair value measurements. In addition, the new guidance clarifies existing disclosure requirements related to the level of disaggregation of classes of assets and liabilities and provides further detail about inputs and valuation techniques used for fair value measurement. The new guidance for Level I and Level II is effective for the Company beginning January 1, 2010 and the new disclosures related to Level III fair value measurements are effective for the Company beginning January 1, 2011. See Note 8 for information on the Company's fair value measurements and disclosures required by the adoption of these amendments. In August 2010, the FASB issued Accounting Standards Update ("ASU") No. 2010-24, Presentation of Insurance Claims and Related Insurance Recoveries, which clarifies that a health care entity should not net insurance recoveries against a related claim liability. Additionally, the amount of the claim liability should be determined without consideration of insurance recoveries. The adoption of ASU No. 2010-24 is effective for the Company beginning January 1, 2011. The adoption of ASU No. 2010-24 is not expected to have a material impact on the Company's financial statements. 4. MEDICARE PART D On January 1, 2006, the Company began serving as a plan sponsor offering Medicare Part D prescription drug insurance coverage under a contract with CMS. Under the Medicare Part D program, there are six separate elements of payment received by the Company during the plan year. These payment elements are as follows: CMS Premium -- CMS pays a fixed monthly premium per member to the Company for the entire plan year. Member Premium -- Certain members pay a fixed monthly premium to the Company for the entire plan year in addition to the CMS premium for expanded insurance coverage. Low-Income Premium Subsidy -- For qualifying low-income members, CMS pays some or all of the member's monthly premiums to the Company on the member's behalf. -5- Catastrophic Reinsurance Subsidy -- CMS pays the Company a cost reimbursement amount monthly to fund the CMS obligation to pay approximately 80% of the costs incurred by individual members in excess of the individual annual out-of-pocket maximum of four thousand five hundred fifty dollars. Low-Income Member Cost-Sharing Subsidy ("LICS") -- For qualifying low-income members, CMS pays some or all of a member's cost-sharing amounts, such as deductibles and coinsurance on the member's behalf. The cost-sharing subsidy is funded by CMS through monthly payments to the Company. The Company administers and pays the subsidized portion of the claims on behalf of CMS, and a settlement payment is made between CMS and the Company based on actual claims experience, subsequent to the end of the plan year. CMS Risk Share -- If the ultimate per member per month benefit cost of any Medicare Part D plan varies more than 5% above or below the level estimated in the original bid submitted by the Company and approved by CMS, there is a risk-share settlement with CMS that is settled subsequent to the end of the plan year. The risk-share adjustment, if any, is recorded as an adjustment to premium revenues and other receivables or liabilities. The CMS premium, the member premium, the low-income subsidy, and the catastrophic reinsurance subsidy represent payments for the Company's insurance risk coverage under the Medicare Part D program and, therefore, are recorded in Medicare premium revenues in Report #2: Revenue, Expenses and Net Worth. Premium revenues are recognized ratably over the period in which eligible individuals are entitled to receive prescription drug benefits. Premium payments received in advance of the applicable service period are recorded as unearned premiums in Report #1- Part B: Liabilities and Net Worth. The LICS represents cost reimbursements under the Medicare Part D program. The Company is fully reimbursed by CMS for costs incurred for these contract elements, and accordingly, there is no insurance risk to the Company. Pharmacy benefit costs and administrative costs under the contract are expensed as incurred and are recognized in medical and hospital expenses in Report #2: Revenue, Expenses and Net Worth. The Company's Medicare Part D benefit design includes both the basic Medicare Part D benefit ("Defined Standard benefit") and a supplemental benefit. For the basic Medicare Part D benefit, the Company is responsible for approximately 66% of the Medicare beneficiary's drug costs up to the initial coverage limit of two thousand eight hundred forty dollars, while the beneficiary is responsible for 100% of the drugs costs, from two thousand eight hundred forty dollars to six thousand four hundred forty seven dollars and fifty cents. The supplemental benefit, for which the Company receives no Medicare Part D reimbursement, fills in the gap between two thousand eight hundred forty dollars, and six thousand four hundred forty seven dollars and fifty cents with generic drug coverage. The Company's supplemental coverage also raises the initial coverage limit above two thousand eight hundred forty dollars. 5. INVESTMENTS Investments restricted for use in the Company's various nonqualified deferred retirement plans amounted to $2,572 at December 31, 2011. The gross unrealized losses on the Company's investments were caused by interest rate increases and general downturn in market conditions. -6- Restricted Cash -- Pursuant to requirements of the Knox-Keene Health Care Services Plan Act, $300 has been deposited and assigned to the Department as of December 31, 2011. Interest income accrues to the Company. Effective May 26, 2004, the Company changed from a guaranteed cost workers' compensation insurance program to a large deductible program. Effective May 26, 2006, the Company changed back to a guaranteed cost workers' compensation insurance program. 6. PROPERTY AND EQUIPMENT Property and equipment as of December 31, 2011 consist of the following: Computer equipment and software Office furniture and equipment Leasehold improvements Vehicles $ 13,102 11,061 14,730 414 39,307 Less accumulated depreciation and amortization (22,042) 17,265 Construction in progress -- leasehold improvements Total 7. MEDICAL CLAIMS PAYABLE 418 $ 17,683 Liabilities for unpaid claims and claim expenses are estimates of payments to be made under health coverage for reported but unpaid claims and for IBNR claims. Management develops these estimates using actuarial methods based upon historical data for payment patterns, cost trends, product mix, seasonality, utilization of health care services, and other relevant factors. 8. FAIR VALUE MEASUREMENTS FASB ASC 820 defines fair value, establishes a framework for measuring fair value in accordance with existing GAAP, and expands disclosures about fair value measurements. Assets and liabilities recorded at fair value in Report #1- Part A: Assets and Part B: Liabilities and Net Worth are categorized based upon the level of judgment associated with the inputs used to measure their fair value and the level of market price observability. Investments measured and reported at fair value using level inputs, as defined by FASB ASC 820, are classified and disclosed in one of the following categories: Level 1 -- Quoted prices are available in active markets for identical investments as of the reporting date. The types of investments included in Level 1 include equities and mutual funds. As required by FASB ASC 820, the quoted price for these investments is not adjusted, even in situations where the Company holds a large position and a sale could reasonably impact the quoted price. -7- Level 2 -- Pricing inputs are other than quoted prices in active markets, which are either directly or indirectly observable as of the reporting date, and fair value is determined through the use of models or other valuation methodologies. Investments that are generally included in this category include U.S. government and agency obligations, mortgage-backed securities, asset-backed securities, corporate bonds, and commingled funds. Level 3 -- Pricing inputs are unobservable for the investment and include situations where there is little, if any, market activity for the investment. The inputs used in the determination of fair value require significant management judgment or estimation. Management's estimates are based on information provided by fund managers, the general partners, or third-party service providers using methods and significant assumptions the Company considers appropriate based on its understanding of the characteristics of the investments. In certain cases, the inputs used to measure fair value may fall into different levels of the fair value hierarchy. In such cases, an investment's level within the fair value hierarchy is based on the lowest level of input that is significant to the fair value measurement. Management's assessment of the significance of a particular input to the fair value measurement in its entirety requires judgment and considers factors specific to the investment. 9. EMPLOYEE BENEFITS The Company provides a defined contribution retirement plan ("retirement plan") organized under IRC Section 403(b) for its employees. The Company makes discretionary contributions of approximately 5% of gross salaries on behalf of all eligible employees with a minimum of one year of service and one thousand hours worked. Employees are immediately vested in the 5% contribution. Effective January 1, 2006, the Company began to match employee's contributions. The retirement plan provides for an employer-matching contribution of an amount equal to 50% of the first 4% of pay an employee's contributes as salary deferral contributions. Employees are eligible after twelve months of service and one thousand hours worked for the employer match. The matching contribution is vested after three years of service. The employee's maximum contribution limit is sixteen thousand five hundred dollars for the year; employees over age fifty may contribute up to twenty two thousand dollars for the year; based on the Internal Revenue Service ("IRS") annual compensation limit of two hundred forty five thousand dollars for the year. Employees are immediately 100% vested. The Company also sponsors a 457(b) deferred compensation plan to benefit certain management employees. Participants are eligible to defer from 1% to 100% of their compensation for the year up to the IRS dollar limit of sixteen thousand dollars for the year, adjusted in future years for cost of living increases in accordance with Section 457(e) (15) of the IRC. The Company also contributes 5% of a participants' earnings to the 457(b) plan on a quarterly basis. The employer contribution is also included in the IRS dollar limit. Effective January 1, 2006, the Company established a 457(f) executive nonqualified retirement plan that covers certain key executives. This plan is maintained for the purpose of providing retirement benefits for a select group of management. The Company credits the employer account of each active participant on a quarterly basis. A participant becomes vested in the employer contribution account upon completion of their chosen vesting option while the participant is an employee. The Company has established a Key Employee Share Option Plan ("KEYSOP") that covers certain key executives. The KEYSOP provides for incentive payments that will be made upon completion of a -8- specified vesting period and are generally dependent upon continued employment of the participants. The plan has been frozen since May 2002. The Company no longer makes contributions to this plan. 10. RELATED-PARTY TRANSACTIONS The Company provides administrative services in support of the operations of SCAN Health Plan Arizona, SCAN Long Term Care, The SCAN Foundation, and SCAN Group. These affiliates have agreed to reimburse the Company for providing and arranging accounting, financial, and other services. The amount of the expenses to be reimbursed is allocated based on time allocations provided by each department of the Company or as a percentage of SCAN membership or headcount. The amount of the expenses is reported in Report #2: Revenue, Expenses and Net Worth and the amount reimbursed to the Company for the services provided by the Company were recorded as reductions of affiliate receivables in Report #1-Part A: Assets. SCAN Group assumed direct responsibility for providing certain administrative services in support of the operations of the Company. The Company has agreed to reimburse SCAN Group for providing and arranging internal audit, legal, information technology, human resources, facilities, and other services. The amount of expenses to be reimbursed is allocated based on time allocations provided by each department of SCAN Group or as a percentage of SCAN membership or headcount. The charges for these services to the Company were recorded in Report #2 Revenue, Expenses and Net Worth. Intercompany transactions between the Company and affiliates represent costs incurred in the ordinary course of business by, or on behalf of, the Company. Intercompany receivable and payable amounts are settled through intercompany cash settlements within 30 days of year-end. On March 28, 2011, the Company issued a $50,000 note receivable to SCAN Health Plan Arizona with no stated interest rate (the "Note"). The Note was approved by the Department on March 22, 2011. The Note is due in full within 90 days of the ending date of the financial statements filed with the Arizona Department of Insurance ("DOI") in which SCAN Health Plan Arizona reports risk-based capital, as if the Note has been paid, of 300% of the authorized control level. Repayment is subject to the approval of the DOI. As of December 31, 2011, there is an allowance provision of $14,843 on the $50,000 note receivable resulting in a net book value for the note receivable of $35,157.0 11. COMMITMENTS AND CONTINGENCIES Cash Concentration -- The Company maintains the majority of its cash and cash equivalents in one financial institution, which subjects the Company to concentrations of credit risk related to temporary cash investments. Credit Concentration -- A substantial portion of operating revenues for the twelve months ended December 31, 2011 result from contracts with CMS. CMS cancellation or nonrenewal of its contracts with the Company or nonpayment of amounts due to the Company would have a material adverse effect on the Company's Net Worth. Medical Claims Risk -- The Company is exposed to certain medical claims risk due to the nature of its operations. The major portion of medical services provided for the Company's members is performed under contract; however, the Company regularly incurs costs for noncontracted services from providers. In addition, in the event of default or financial difficulties with certain providers, the Company could be liable for outstanding claims, which, if substantial, could have a material adverse effect on the Company's Net Worth. -9- Cost Containment Measures -- Both government and private pay sources have instituted cost containment measures designed to limit payments made to providers of health care services, and there can be no assurance that future measures designed to limit payments made to providers will not adversely affect the Company's Net Worth. Regulatory Changes -- As discussed in Note 1 above, prior to January 1, 2008, the Company operated as a MAO with a special waiver as a Social HMO under a national demonstration program administered by CMS in four counties: Los Angeles, Orange, Riverside, and San Bernardino. The Company commenced operations as a MAO without the special waiver beginning in 2008. As a MAO without the special waiver, revenue per member has been reduced as compared to the levels when the waiver was in place; however, other additional medical services offered to its members as a Social HMO have been reduced as well. Professional Liability Insurance -- The Company carries managed care errors and omissions liability coverage with limits of five million dollars per claim and five million dollars in aggregate in any one year. In the ordinary course of business, the Company is subject to the claims of its members arising out of treatment authorization decisions and other managed health care operations. Regulatory Proceedings and Litigation -- In the ordinary course of its business operations, the Company is subject to periodic reviews by various regulatory agencies with respect to the Company's compliance with a wide variety of rules and regulations applicable to its business, which may result in the assessment of regulatory fines or penalties. Additionally, the Company is also party to various legal actions arising in the normal course of business. These other regulatory and legal proceedings are subject to many uncertainties, and, given their complexity and scope, their final outcome cannot be predicted at this time. However, after taking into consideration legal counsel's evaluation of such legal and regulatory actions, and except as described in Note 14, management believes the outcome of these matters will not have a material adverse effect on the Company's Net Worth or Cash Flows. Health Reform -- On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into law, and then, on March 30, 2010, President Obama signed into law the Health Care and Education Affordability Reconciliation Act of 2010 (collectively, "health insurance reform"). Health insurance reform provisions include limiting Medicare Advantage payment rates, mandatory issuance of insurance coverage, requirements that would limit the ability of health plans and insurers to vary premiums based on assessments of underlying risk, and stipulating annual rebates to enrollees if the amount of premium revenues expended on medical costs falls below prescribed ratios for group and individual health insurance coverage. The Company is evaluating the effect that health insurance reform may have on its financial position and currently expects that the health insurance reform provisions would reduce its premium rates and revenues beginning in calendar year 2012. Guarantees and Indemnities -- From time to time, the Company enters into certain types of contracts that contingently require the Company to indemnify parties against third-party claims. These contracts primarily relate to (i) certain real estate leases, under which the Company may be required to indemnify property owners for environmental or other liabilities and other claims arising from the Company's use of the applicable premises and (ii) certain agreements with the Company's officers, directors, and employees, under which the Company may be required to indemnify such persons for liabilities arising out of their employment relationship. The terms of such obligations vary by contract and, in most instances, a specific or maximum dollar amount is not explicitly stated therein. Generally, obligation amounts under these contracts can not be reasonably estimated until a specific claim is asserted. No claims have been asserted as of December 31, 2011. Consequently, no liabilities have been recorded for these obligations on the Company's Report #1: - Liabilities and Net Worth. - 10 - 12. INVESTIGATIONS AND EXAMINATIONS Investigation -- In March 2010, the Company received a subpoena for documents from the Office of Inspector General (the "OIG"), U.S. Department of Health and Human Services. The Company thereafter was notified of parallel investigations being conducted by the California Attorney General (criminal and civil) (the "Cal AG") and the United States Attorney's Office for the Central District of California (civil) (the "DOJ"). The parallel investigations focus on the Company's receipt of program funds under various contracts with CMS and the DHCS during the period 2001 to 2009. In particular, the parallel investigations focus on whether the Company was overpaid on any contract in place with CMS and DHCS during any of the years in question and whether any current or former Company employee knowingly sought to obtain money for the Company that the Company allegedly was not entitled to receive. In addition, OIG and DOJ are investigating whether the Company allegedly received excess payments from CMS by failing to submit proper HCC risk scores for certain beneficiaries. The Company is cooperating with these investigations and has voluntarily produced records and made witnesses available for interview by investigators. The State and Federal investigations are ongoing. Promptly after learning of the existence of the investigations, the SCAN Group Board of Directors appointed a special committee (the "Special Committee") consisting solely of independent directors to address issues arising out of the investigations. The Special Committee engaged independent counsel and outside forensic accountants to assist in conducting an internal investigation. To date, the Special Committee has not received any evidence suggesting intentional misconduct on the part of the Company or any of its current or former employees. At the Board of Directors' direction, in October 2010, Independent counsel shared the evidence adduced as part of the independent investigation with investigators from the Cal AG, the OIG, and DOJ. In March 2011, Independent counsel made a separate presentation regarding the HCC risk score issue to Investigators from OIG and DOJ. Notwithstanding the evidence adduced during the internal investigation, and the various defenses the Company could mount to any potential claims brought by the State and/or Federal government, in December 2010, the Company entered into global settlement negotiations with the State and Federal governments in an attempt to resolve any potential claims and to avoid the costs and uncertainty of litigation. The Company offered to pay $125 million to resolve any and all claims associated with the contracts at issue with CMS and DHCS. In December 2010, the Company recorded a provision of $125 million to accounts payable and accrued expenses liabilities to record the proposed settlement offer. Settlement discussions are ongoing, and the Company cannot predict whether or when a settlement will occur or whether criminal or civil court proceedings might be initiated against the Company or any of its current or former employees or officers. The Cal AG and the DOJ have indicated that a counter-offer is forthcoming to resolve any and all civil claims but, to date, no counter has been received. The Company has entered into tolling agreements with both the Cal AG and the DOJ while settlement negotiations continue. It is reasonably possible that a change in the estimated liability may occur in subsequent periods to resolve this matter in amounts not currently determinable by the Company. An adverse resolution of any of these investigations could have a material adverse effect on the Company's business, including substantial financial payments and potential exclusion from participation in State or Federal health care programs. Examination -- CMS has been performing Risk Adjustment Data Validation ("RADV") audits of selected MAO plans to validate provider coding practices under the risk adjustment model used to - 11 - calculate the premium paid for each MAO member. One of the Company's contracts in California, which serves Los Angeles, Orange, San Bernardino and Riverside counties, has been selected by CMS for audit for the 2007 contract year ("2007 RADV audit") as part of this broad CMS audit program. The Company is cooperating with the audit. This coding audit may result in prospective or retrospective adjustments to payments made to the Company pursuant to its CMS Medicare contract. In December 2010, CMS published a proposed methodology for payment adjustments determined as a result of its various RADV audits, including its methods for sampling, payment error calculation, and extrapolation of the error rate across the relevant plan population. In January 2011, CMS announced that this draft methodology would be revised to reflect public comments. CMS has not disclosed a specific timetable for finalizing its RADV audit sampling and payment error calculation methodology. Because the RADV audit methodology is not final and is subject to modification, there is significant uncertainty as to how CMS will determine payments adjustments to the Company arising out of the 2007 RADV audit. Accordingly, management cannot estimate the likelihood or amount of any possible financial impact that may result from the 2007 RADV audit and, therefore, has not recorded any related accruals. However, an adverse resolution of this audit, could, if substantial, have a material adverse effect on the Company's business and net assets. ****** - 12 - I I II II I IFMIIE I I I Iwlm Search Enforcement Actions Search Enforcement Actions Actions Search Enforcement 2/22/12 12:31 PMPM 2/22/12 12:31 12:3 2/22/12 Search Search Enforcement Actions Search Enforcement Actions Enforcement Actions Enforcement Actions Actions by Organization Enforcement Actions by Organization Enforcement by Organization Search Enforcement Actions \ Search Results Search Enforcement Actions \ Search Results Search Enforcement Actions \ Search Results There are 2 2 are 2 enforcement actionsmeet meet search criteria. ThereThere enforcement actions that that your your criteria. are enforcement actions that meet your search search criteria. Scan HealthHealth Plan Scan Scan Plan Health Plan Org. Type Type Org. Type Org. Health Plan Health Plan Plan Health Violation # # Violation Violation # 1375.4 1375.4 1375.4 1300.75.4.5 1300.75.4.5 1300.75.4.5 Failure Failure to comply Plan/RBO contractual requirements. Failure to comply with with Plan/RBO contractual requirements. to comply with Plan/RBO contractual requirements. Failure Failure to have adequate procedures for ofof Solvency Reg reports Failure to have adequate procedures for review Solvency Reg reports reports to have adequate procedures for review review of Solvency Reg and toto take appropriate action when when RBOscomply comply the specified and take to take appropriate when RBOs fail totofail to with the specified and appropriate action action RBOs fail comply with with the specified Regs. Regs. Regs. Action Action Date Action Date Date 11/16/2009 11/16/2009 11/16/2009 Penalty Penalty Penalty ----- Scan HealthHealth Plan Scan Scan Plan Health Plan Org. Type Type Org. Type Org. Health Plan Health Plan Plan Health Violation # # Violation Violation # 1375.4 1375.4 1375.4 1300.75.4.5 1300.75.4.5 1300.75.4.5 Failure Failure to comply Plan/RBO contractual requirements. Failure to comply with with Plan/RBO contractual requirements. to comply with Plan/RBO contractual requirements. Failure Failure to have adequate procedures for ofof Solvency Reg reports Failure to have adequate procedures for review Solvency Reg reports reports to have adequate procedures for review review of Solvency Reg and toto take appropriate action when when RBOscomply comply the specified and take to take appropriate when RBOs fail totofail to with the specified and appropriate action action RBOs fail comply with with the specified Regs. Regs. Regs. Action Action Date Action Date Date 07/03/2008 07/03/2008 07/03/2008 Penalty Penalty Penalty ----- Top ofof Page Page Top Pageof Top DMHC Home | About the About the DMHC | Consumers | Plans | Plans | Providers |of Patient Patient Advocate | |Site Map UsUs DMHC DMHC| Home |the DMHC | Consumers | Health Health Providers | Office Patient of Advocate | Site Map | ContactContact Us Home About DMHC | Consumers | Health Plans | Providers | Office of Office Advocate | Site Map Contact | (C) (C) State of California. Conditions of Use Privacy|Policy Policy State (C) California. Conditions of Use | of Privacy Policy of State of California. Conditions | Use Privacy http://wpso.dmhc.ca.gov/enfactions/actionSearch.aspx http://wpso.dmhc.ca.gov/enfactions/actionSearch.aspx http://wpso.dmhc.ca.gov/enfactions/actionSearch.aspx Page 1 of of 2 1 Page 1 2 Page I I II II I IFMIIE I I I Iwlm DHCS Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members 2009 MEASURE PBP Breast Cancer Screening - non SNP Measure Colorectal Cancer Screening Glaucoma Screening in Older Adults Care for Older Adults - New for 2009 Rpt Yr Advance Care Planning Medication Review Functional Status Assessment Pain Screening Spirometry Testing for COPD Pharmacotherapy Mgmt of COPD Exacerbations Controlling Blood Pressure Persistence of BB Use After a Heart Attack Osteoporosis Management After a Fracture Antidepressant Medication Mgmt Follow Up After Hospitalization Annual Monitoring for Patients of Persistent Medications (total) Medication Reconciliation Post Discharge Potentially Harmful Drug-Ds Interaction in the Elderly (total) Use of High Risk Medications in the Elderly One Prescription Two Prescriptions Board Certification Family Medicine Internal Medicine Geriatrics DHCS H5425 DHCS H9104 2010 DHCS H5425 DHCS H9104 DHCS H5425 73.08% 65.08% 72.80% 63.67% 75.79% 2011 DHCS H9104 76.17% NA NA NA NA NA NA DHCS Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members 2009 MEASURE DHCS H5425 DHCS H9104 2010 DHCS H5425 DHCS H9104 DHCS H5425 2011 DHCS H9104 PBP Other Specialties Plan All Cause Readmission Avg Adj Prob - new for 2011 Rept Yr Quality Improvement Projects for CA Dept Healthcare Services Stroke Mortality Rates All NR 8.66% Cohort1 (hypertension+diabetes+dyslipidemia) Only NR 7.69% Cohort2 Afib Only NR 10.54% Cohort3 (hypertension+diabetes+dyslipidemia) +Afib NR 10.83% COPD Spirometry and Bronchodilator SPIROMETRY NR 17.49% BRONCHO (PCE) - 30 Days 77.27% 60.44% BRONCHO (PCE) - 6 Months 84.09% 74.68% California DHCS Selected Measure 7.87% 7.94% 5.63% 7.20% 7.48% 7.12% 4.70% 6.21% NR 9.20% NR 8.76% NR 10.99% NR 10.61% NR NR NR 20.42% 66.52% 76.02% 27.14% 69.81% 92.45% 19.07% 68.26% 81.44% SNP Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members 2009 H5425 H5425 DSNP DSNP LA RV 10 54.84% 62.75% NR NR NR NR NA NA 53.70% NA NA NA NA 86.29% NR NA 11 2010 H5425 H5425 H5425 H9104 DSNP DSNP DSNP DSNP LA RV SB LA 10 11 12 NA NA 18.00% 48.67% 20.00% 25.33% NA NA 55.70% NA NA NA NA 84.11% 7.89% NA 6 NA 83.95% 15.47% 58.27% 42.09% 27.70% NA NA 57.26% NA NA NA NA 92.89% 23.38% 26.47% H9104 DSNP RV 8 NA NA MEASURE PBP Breast Cancer Screening - non SNP Measure Colorectal Cancer Screening Glaucoma Screening in Older Adults Care for Older Adults - New for 2009 Rpt Yr Advance Care Planning Medication Review Functional Status Assessment Pain Screening Spirometry Testing for COPD Pharmacotherapy Mgmt of COPD Exacerbations Controlling Blood Pressure Persistence of BB Use After a Heart Attack Osteoporosis Management After a Fracture Antidepressant Medication Mgmt Follow Up After Hospitalization Annual Monitoring for Patients of Persistent Medications (total) Medication Reconciliation Post Discharge Potentially Harmful Drug-Ds Interaction in the Elderly (total) Use of High Risk Medications in the Elderly One Prescription Two Prescriptions Board Certification Family Medicine Internal Medicine Geriatrics H9104 DSNP SB 9 NA NA NA 61.40% 43.33% NA 68.00% 51.22% NR NR NR NR NA NA NA NA NA NA NA NA NR NA 7.54% 48.42% 15.57% 18.00% NA NA 52.47% NA NA NA NA 85.74% 21.26% NA 8.72% 45.64% 22.56% 23.08% NA NA 51.19% NA NA NA NA 86.72% 14.29% NA 18.69% 18.75% 52.34% 56.25% 34.58% 48.44% 24.30% 42.19% NA NA NA NA 63.41% 63.33% NA NA NA NA NA NA NA NA 93.83% 100.00% NA 21.88% NA NA 49.23% 21.54% NR NR NR 41.86% 36.36% 39.09% 32.32% 35.95% 49.10% 42.99% 10.70% 4.55% 13.85% 9.60% 12.42% 15.77% 14.02% NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR NR SNP Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members 2009 H5425 H5425 DSNP DSNP LA RV 10 NR 11 NR 2010 H5425 H5425 H5425 H9104 DSNP DSNP DSNP DSNP LA RV SB LA 10 NR 11 NR 12 NR 6 NR H9104 DSNP RV 8 NR MEASURE H9104 DSNP SB 9 NR PBP Other Specialties Plan All Cause Readmission Avg Adj Prob - new for 2011 Rept Yr Quality Improvement Projects for CA Dept Healthcare Services Stroke Mortality Rates All NR Cohort1 (hypertension+diabetes+dyslipidemia) Only Cohort2 Afib Only Cohort3 (hypertension+diabetes+dyslipidemia) +Afib COPD Spirometry and Bronchodilator SPIROMETRY BRONCHO (PCE) - 30 Days BRONCHO (PCE) - 6 Months NR NR NR NR NR NR NR 7.29% 9.68% NR 7.82% 7.91% 7.79% NR 7.23% 8.00% NR 6.93% 7.63% 6.78% NR NR NR NR 9.49% 8.36% 9.79% NR NR NR NR 11.11% 8.96% 12.39% NR NR NR NR NR NR NR NR NR NR 24.02% 13.65% NR 69.61% 65.00% NR 80.39% 70.00% 16.19% NR NR SNP Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members H5425 DSNP LA 10 59.44% 72.97% 46.47% 58.88% 48.66% 24.09% NA NA 54.15% NA NA NA NA 92.69% 25.31% 34.00% 35.45% 11.42% NR NR NR 2011 H5425 DSNP RV 11 H5425 DSNP SB 12 MEASURE PBP Breast Cancer Screening - non SNP Measure Colorectal Cancer Screening Glaucoma Screening in Older Adults Care for Older Adults - New for 2009 Rpt Yr Advance Care Planning Medication Review Functional Status Assessment Pain Screening Spirometry Testing for COPD Pharmacotherapy Mgmt of COPD Exacerbations Controlling Blood Pressure Persistence of BB Use After a Heart Attack Osteoporosis Management After a Fracture Antidepressant Medication Mgmt Follow Up After Hospitalization Annual Monitoring for Patients of Persistent Medications (total) Medication Reconciliation Post Discharge Potentially Harmful Drug-Ds Interaction in the Elderly (total) Use of High Risk Medications in the Elderly One Prescription Two Prescriptions Board Certification Family Medicine Internal Medicine Geriatrics 56.12% 55.43% 72.85% 74.67% 51.09% 67.15% 58.15% 27.01% NA NA 62.50% NA NA NA NA 93.54% 27.37% NA 54.46% 66.77% 56.62% 29.54% NA NA 69.32% NA NA NA NA 93.63% 22.95% NA 34.43% 41.28% 8.96% 14.68% NR NR NR NR NR NR SNP Quality Performance Indicators including HEDIS for SCAN Health Plan's senior members H5425 DSNP LA 2011 H5425 DSNP RV H5425 DSNP SB MEASURE PBP 10 Other Specialties NR Plan All Cause Readmission Avg Adj Prob - new for 2011 Rept Yr 14.45% 11 12 NR NR 14.12% 19.55% Quality Improvement Projects for CA Dept Healthcare Service Stroke Mortality Rates All 5.37% 4.84% 7.84% Cohort1 (hypertension+diabetes+dyslipidemia) Only 4.81% 3.92% 5.13% Cohort2 Afib Only NR NR NR Cohort3 (hypertension+diabetes+dyslipidemia) +Afib NR NR NR COPD Spirometry and Bronchodilator SPIROMETRY 27.14% NR NR BRONCHO (PCE) - 30 Days NR NR NR BRONCHO (PCE) - 6 Months NR NR NR I I II II I IFMIIE I I I Iwlm Response to Mandatory Qualifications #12 SCAN Health Plan meets the following three of five criteria for demonstrating local stakeholder involvement: The Applicant has provided at least five letters of support from the community, with sources including individual dual eligible consumers, advocates for seniors and persons with disabilities, organizations representing LTSS, such as community-based organizations, and/or individual health care providers. Letters from agencies are included in appendix #8. The Applicant sought and accepted-community-level stakeholder input into the development of the Application, with specific examples provided of how the plan was developed or changed in response to community comment. SCAN Health Plan approached the design and development of this Application through the development of the Member and Community Advisory Committee. Our inaugural meeting took place October 2011. During this meeting, committee members collaborated to establish a committee charter and mission statement as well as review SCAN's submission regarding the DHCS request for comment on draft frameworks. The Committee also met via conference call in January to discuss SCAN's response to the Draft RFS and proposal to submit a response to CMS regarding the CCMI Challenge Grant, included in Section 9. The group met again in person on January 27, 2012 to further discuss these initiatives and provide suggestions which SCAN has included in the final conceptualizing of this proposal. The Applicant has conducted a program of stakeholder involvement (with the Applicant providing a narrative of all activities designed to obtain community input). SCAN Health Plan currently has several ways in which stakeholders are engaged to provide input regarding benefits and future planning for enhancing the model of care. Section 5.4 of the RFS details current and future engagement. This includes: o SCAN developed a stakeholder engagement strategy in preparation for the 2012 annual election period. Stakeholders participating in these discussions include dual eligible members, family/caregivers, community agencies, contractors, LTSS providers, and contracted medical and behavioral health providers. Planning and preparation for this state contract have been taking place since 2011. As part of this process, SCAN has communicated with several health plans to assess their capabilities to serve dually eligible aged and disabled members and whether a partnership might be feasible. We have also reached out to all the MSSP providers in each county in which SCAN is applying for the Demonstration to discuss coordination of the LTSS benefit. SCAN has also sought input from our members in these discussions. In addition to engaging our Community Advisory Committee and conducting member forums (described below), SCAN is convening focus groups of FFS dual eligibles. These groups will play an integral role in gauging beneficiary preferences regarding the network and o location of providers, determining which benefits this population believes are most important, customer service, and preferred communication methods. o SCAN intends to employ our regular means of stakeholder engagement, which have proven effective in assessing members' needs and preferences: Community Advisory Committee: The Community Advisory Committee is comprised of dual eligible members and one provider from SCAN's in-home and community-based services network. The Committee meets quarterly, with two meetings held in English, and two meetings held in Spanish. Members play an integral role in developing and improving upon different programs. For example, the Committee is often asked to review articles and brochures for readability, clarity of message, and appearance. In another meeting, member feedback was solicited on how SCAN could improve quality by assuring that members get necessary tests and screenings. When SCAN rolled out our Care Transitions program-- which assists members in successfully transferring from hospital to home or from hospital to skilled nursing facility--Committee members provided important suggestions about how to explain and present the program. Senior Advisory Committee: The Senior Advisory Committee, also composed of SCAN members, includes both Medicare-only members and dual eligible members, and a contracted provider. SCAN's CEO serves as an ex officio Committee member. Similar to the Community Advisory Committee, this Committee provides feedback on member needs, communication vehicles, programs, and benefits. Member and Community Advisory Committee: In 2011, SCAN convened a Member and Community Advisory Committee to strengthen, monitor, and improve care coordination as this new system of care is launched. This group has strategic representation from diverse constituency areas, including mental health, community services, long-term care, caregiver services, and cultural needs. Area Agencies on Aging, dual eligible members and family members are also represented on the board and participate in these discussions. Going forward, the Committee will be expanded to include substance use services, independent living center services, CBAS centers, and additional health plan members and consumers. Member Forums: Each fall, SCAN executives travel throughout SCAN's service area to meet with members, their caregivers, and potential members at "Straight Talk" events. During these meetings, the executives explain new benefits, provide attendees with an understanding of the direction of the organization, and answer questions. Straight Talks serve as an important forum for SCAN to better understand members' needs, and for members to ask any questions about SCAN or about their health care in general. In 2011, over 11,000 members attended a total of 29 sessions, hosted in 21 locations in 9 counties in California and Arizona. Another example of meaningfully seeking community input has occurred in San Diego. SCAN is a member of the Duals Demonstration Stakeholder Advisory Committee organized by San Diego County's Healthy San Diego stakeholders and the Aging and Independent Services Department (AIS). The group held its first organizational meeting in February. The committee includes all of the San Diego County Managed Care plans responding to the RFS and all of the local LTSS providers. Also participating are consumer representatives including the Consumer Center for Health Education and Advocacy, County In-Home Supportive Services (IHSS), County Behavioral Health Services, Program of All-Inclusive Care for the Elderly (PACE), Community Based Adult Services (CBAS), Senior Alliance, United Domestic Workers (UDW), Hospital Association of San Diego and Imperial County, Community Clinics, AIS Aging Services (ADRC), a SNF representative, at least three dual eligible beneficiaries, the San Diego Regional Center, Access to Independence, and the IHSS Public Authority. In counties where similar county-inspired stakeholder involvement groups are available, SCAN will be an active and willing participant. In counties where this structure does not exist, we will create county specific Advisory Committees following our Advisory Committee model. 1 I SCAN Health Plan ADVISORY COMMITTEE CHARTER October 21, 2011 Introduction SCAN Health Plan (S CAN) will estab lish a nd m aintain a Mem ber/Community Advisory Committee (Comm ittee) to support SCAN's mission to continue to find innovative ways to enhance seniors' and disabled i ndividuals' ability to m anage thei r h ealth and to co ntrol where and how they live. The Comm ittee will provide insight and feedback on issues that affect those served by SCAN, with the dual objectives of i mproving SCAN's delivery of care to its m embers and increasing awareness of SCAN in the community. Section I: Committee Roles and Objectives The Mem ber/Community Advisory Comm ittee will serve in an adviso ry capac ity and provide insight and feedback to SCAN regarding pub lic policy, SCAN program s and community issues, and promote a collaborative effort to enhance healthcare services delivered to SCAN m embers. Key objectives may include, but are not limited to: A. Discuss public policy including proposed federal/ state/local legislative/regulatory changes and provide insight and feedback with respect to the effect of such policy and changes on SCAN m embers for the purpose of infor ming SCAN leadership regarding planning considerations. B. Review and provide comments regarding ongo ing and/or proposed Comm unity Outreach activities to ensure that community needs are being addressed. C. Bring current topics an d issues fro m the Co mmittee members' respective areas of expertise to the Committee for discussion to facilitate planning by SCAN to meet current and emerging member needs. D. Review and provide comments regarding SCAN m ember communication m aterials, education, and assessment methods. E. Recruit additional members for the Committee from constituencies/stakeholders that are no t then rep resented ( e.g., nursing facility, alternative residen tial setting, and be havioral health services). One Committee meeting will be held each calendar quarter. Section II: Committee Composition and Membership Once f ully estab lished, the Comm ittee will hav e fourteen (14) m embers. The Committee will select members from various cons tituency/stakeholder groups and/or service/setting types so as to reflect the diversity and com plexity of those served by S CAN. Those constitu encies are as follows: o o o o o o o City/County Social Services Mental Health Disability Services/Independent Living Long-term Care Caregivers Community Services Cultural Needs Charter Page 1 October 21, 2011 o o o SCAN Health Plan Member (3) SCAN Health Plan Family Member (2) Member At Large (2) All committee members will serve a two (2) year te rm with term lim it of two (2) consecutive terms with the exception of Ment al Health and City/County Soci al Services positions which members, once appointed, m ay be reappointed to unlimited two (2) year term s at the discretion of the SCAN Health Plan Chief Executive Officer Positions as members of the Committee will be offered by SCAN Health Plan through a ppointment by the S CAN Health Plan Chief Executive Officer except with respect to seats he ld by a SCAN Health Plan Mem ber (3), SCAN Health Plan Family Member (2) and Me mber at Large (2) which m ay be determined through an appointment or application process, at the discretion of SCAN Health Plan. All members of the Committee must satisfy the following minimum criteria: o o Work or reside in Los Angeles County. Able to serve a two year term. Section III: Committee Functions Leadership: The Committee will have a Comm ittee Chair who will be elected by the m embers. The Committee Chair will f acilitate Committee meetings. The Comm ittee Chair will also work together with repr esentatives of SCAN Health Plan, as designated by the SCAN Health Plan Chief Executive Officer, to set each m eeting's agenda. The term of t he Comm ittee Chair as Chair will be one year with the option of re-e lection with a term lim it of two (2) consecutive terms. Compensation: Particip ation in th e Committe e is voluntary. SCAN Mem bers who have difficulty attending the m eeting due to lack of transportation, m ay be offered transportation assistance so as to facilitate their participation on the Committee. Resignations/Vacancies: In the event of resignations or vacancies, the SCAN Health Plan Chief Executive Officer or his designee will work with the Committee and identify candidates to invite for appointed positions or will begin an open application process. Section IV: Meeting Schedule and Process The Committee will m eet four tim es per year, once each calendar quarter. These meeting s will be set at the beginning o f each year and this sch edule will be made public. All meetings will be e in person at the SCAN Health P lan's corp orate office in Long Beach, California. Th Committee Chair will facilitate the meeting and all discussions. Designated SCAN Health Plan staff will be present at each meeting to: o Present an update regarding SCAN Health Plan o Answer questions as needed. o Be responsible for relaying information to other SCAN Health Plan staff/departments. o Report on any follow up. Charter Page 2 October 21, 2011 I I II II I IFMIIE I I I Iwlm SCAN Health Plan History of Corrective Action Plans in last five years In 2009, the DHCS Audits and Investigations Division (A & I) conducted a m edical review for the audit period February 1, 2008 through January 31, 2009. Certain deficiencies were iden tified within the following areas: Utilization Managem ent, Continuity of Care, Availability and Accessibility, Member's Rights, and Administrative and Organizational Capacity. The Plan's co rrective action was accepted and closed out by DHCS in 2010. In 2010, the DHCS conducted a Nursing Facility Level of Care (NFLOC) review for the audit period March 1, 2010 through May 31, 2010. The audit was conducted over the course of three separate visits which o ccurred at SCAN offices on the following days: September 28, 2010 through Septem ber 29, 2010; Septem ber 13, 2011 through September 15, 2011, and October 25, 2011 thro ugh October 27, 2011. A fourth and final review occurred at DHCS offices on Nove mber 4, 2011. Deficiencies were identified within the following areas: capitation recovery, DHCS Pre-approval of all Initial NFLOC Assessments, Annual Re-Certification of a ll Existing Mem bers, and capitation rate setting. The Plan received the final aud it report from DHCS on Dece mber 27, 2011. The Plan's corrective action is currently under development. I I II II I IFMIIE I I I Iwlm NICK MACCHIONE, FACHE DIRECTOR DEAN ARABATZIS CHIEF OPERATIONS OFFICER ([ountp of $an 1!liego HEALTH AND HUMAN SERVICES AGENCY 1600 PACIFIC HIGHWAY, SAN DIEGO, CA 92101-2417 (619) 515-6555? FAX (619) 515-6556 February 8, 2012 Letter of Agreement to Work in Good Faith: With the passage of AB lO40 in 1995 supporting the development of integrated care models, in February 1999, with Board of Supervisors support, San Diego County began a 12 year effort to implement an integrated system of care for seniors and persons with disabilities through the Long Term Care Integration Project (LTCIP). San Diego County's Health and Human Services Agency (HHSA), through its Aging & Independence Services (AIS) Department, received funding from a variety of sources including three planning grants and two demonstration grants from the State Department of Health Care Services totaling $750,000, as well as additional funding from the California Department on Aging ($610,000), the County of San Diego ($500,000), the California Endowment ($400,000) and the Alliance Healthcare Foundation ($250,000). More than 800 stakeholders (health and social service providers, aging and disabled consumers and advocates), have spent more than 30,000 hours over 12 years to envision and recommend a better model of care for low income seniors and persons with disabilities in our community. Their motivation came from the recognition of the difficulty these individuals and their caregivers have in navigating the fragmented and duplicative network of medical, social, and long-term care services. "'. , . After thorough examination of various service delivery models, in January 2001 by consensus decision, LTCIP stakeholders recommended exploring the feasibility of using San Diego County's existing geographic Medi-Cal managed care program, Healthy San Diego (HSD), as the preferred delivery system model to explore. Referred to as the "HSD+ model," it would have built on the "medical home" approach provided by the County's Healthy Sari-Diego managed care program for Medi-Cal beneficiaries, which now includes all those seniors and persons with disabilities receiving Medi-Cal only. Though legislation was introduced in 2006 to initiate a pilot integration project built upon the HSD+ model, it was not passed. In March 2009, the County Board of Supervisors directed staff to pursue reform of the In-Home Supportive Services (IHSS) program. After reviewing available local and State options for reform, staff returned to the Board in November 2009 with a number of recommendations, including reviewing the opportunity to re-initiate long-term care integration as part of the State's 1115 Hospital Waiver renewal. For the past two years, County staff have been-tracking the development of the dual eligible demonstration project. San Diego responded to the State's Dual Eligible Request for Information (RFI) and presented San Diego's vision for integration at the State's RFI session in August 2011. Letter of Agreement February 8, 2012 Page 2 County staff have been meeting with Healthy San Diego plans and with SCAN Health Plan since last summer to discuss the integration opportunities now afforded by the Dual Eligibles Demonstration Project. The plans have communicated a strong interest in working collaboratively with the County to build upon the long-standing efforts of local stakeholders to create an integrated system for the dual eligibles in our community. Also during the past year, the County contracted with the actuarial firm, PricewaterhouseCoopers, to analyze Medicare, Medi-Cal and home and community based service expenditures to develop a capitated rate for an integrated service delivery system and assist the County with understanding the financial implications for IHSS. Unfortunately, the County consultant has been unable to access needed data to complete these analyses. As the Director of the Health and Human Services Agency (HHSA), which includes Behavioral Health, Aging Services (including IHSS and the Area Agency on Aging! Aging & Disability Resource Connection) I commit my agency to continue working in good faith with health plans to develop an integrated system of care for the dual eligibles in our community that is consistent with the efforts of the past 12 years. With the receipt of necessary data to complete the actuarial analysis, after continued collaboration with the health plans on program design, and with Board of Supervisors' approval, HHSA will be prepared to engage in a formal agreement with health plans to support the Dual Eligibles Demonstration Project. Should you have any questions, please contact Pamela Smith, Director, Aging & Independence Services, at (858) 495-5858. ~~~ NICK MACCHIO~~, Director cc: MPH, FACHE Walt Ekard, Chief Administrative Officer, County of San Diego Stephen Magruder, Senior Deputy, County Counsel Dean Arabatzis, Chief Operations Officer, HHSA Dale Fleming, Director, Strategic Planning and Operational Support, HHSA Jennifer Schaffer, Ph.D., Director, Behavioral Health Pamela B. Smith, Director, Aging & Independence Services, HHSA Mike Van Mouwerik, Director, Financial & Support Services, HHSA PUBLIC AUTHORITY IN-HOME SUPPORTIVE SERVICES nu mzco counrrv February 15, 2012 Letter of Agreement to Work in Good Faith: the passage of AB 1040 in 1995 supporting the development of integrated care models, in February 1999, with Board of Supenrisors support, San Diego County began a 12 year effort to implement an integrated system of re for seniors and persons with disabilities through the Long Temr Care Integration Project (LTCIP). Employee representatives of the County of San Diego ln-Home Supportive Services Public Authority (Public Authority) have participated in the LTCIP since its inception. The Public Authority was established in 2001 by the County of San Diego Board of Supervisors, who serves as the Goveming Body. The Public Authority assists eligible low- income elderly and persons with disabilities (consumers) on the In-Home Supportive Senrices (IHSS) program in San Diego County to live high quality lives in their own homes. Although the PA is an independent public agency, the organization works closely with the _County of San Diego IHSS program and with other programs sewing older adults and persons with disabilities to provide the best possible assistance to consumers and providers. The Public Authority acts as Employer of Record for 21,000 IHSS providers and maintains a relationship with United Domestic Workers as established through a Memorandum of Understanding. In addition, the Public Authority provides Registry services to IHSS consumers, conducts home visits to consumers, and offers voluntary training to a group of provider participants using six-week National Caregiver Training Program modules. In addition, the Public Authority fullills several functions on behalf of the County, including provider payroll using an electronic scanning and software system and provider enrollment for all new IHSS providers. For the past few months, Public Authority staff have been meeting with IHSS representatives, Healthy San Diego plans and with SCAN Health Plan to discuss the integration opportunities now afforded by the Dual Eligibles Demonstration Project. The plans have communicated a strong interest in working collaboratively with the Public Authority to build upon the long-standing efforts of lo stakeholders to create an integrated system for the dual eligibles in our community. As the Executive Director of the IHSS Public Authority, commit our organization to continue working in good faith with health plans to develop an integrated system of re for the dual eligibles in our community. We will coordinate our efforts with those of the County to ensure that we take a consistent approach in working with the health plans to build a system that "QuAr.mr Qurxurv pr-me Letter of Agreement February 15, 2012 Page 2 benefits both IHSS consumers and providers. Public Authority Goveming Body appmval, the Public Authority will be prepared to engage in a fonnal agreement with health plans to support the Dual Eligibles Demonstration Project. Should you have any questions, please contact me at 619-476-6296. . Sincerely, - Albert G. "Bud'T Sayles Executive Director cc: Walt Ekard, Chief Admin@ve Oflicer, County of San Diego Stephen Magruder, Senior Deputy, County Counsel Nick Macchione, Director, HHSA Dean Arabatzis, Chief Operations Oflicer, HHSA Dale Fleming, Director, Strategic Planning and Operational Support, HHSA . Pamela B. Smith, Director, Aging Independence Services, HHSA Mike Van Mouwerik, Director, Financial Support Senrices, HHSA Meredith McCarthy,? Assistant Director, County of San Diego IHSS Public Authority Mum CITY 0F LOS ANGELES or= Acme GENEML CALIFORNIA AN AREA Aazrucv on Acme 3580 WILSHIRE BLVD., STE. 300 Los Arveszuas, CA e001o Amorvro R. MAYOR February 17, 2012 Toby Douglas, Director California Department of Health Care Services - 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, The City of Los Angeles Department of Aging - Area Agency on Aging (LADOA) believes that reater care coordination for Medi and Medicaid "dual eligible" seniors and disabled will help improve beneticiaries' quality of life and potentially yield savings. Dual eligible seniors have unique needs that can be best met by tested and experienced plans. LADOA is supportive of the State of Califomia"s plan to .-partner withmanaged care plans that have demonstrated success in caring for dual eligibles, such as SCAN Health Plan. Serving Southem Califomia seniors, SCAN Health Plan's model of care combines vital medical services with home and community-based services that help keep members/patients in their own homes and out of institutions. The mission of the Los Angeles Department of Aging is to improve the quality of life, independence, health and dignity ofthe City's older population by managing community based senior programs that are comprehensive, coordinated and accessible. Serving the Nation's second largest concentration of persons sixty years and older, among the state's most diverse within a geographic area the size Boston, Cleveland, St. Louis, Pittsburgh, Minneapolis, Milwaukee, San Francisco, and Manhattan combined. LADOA has a long standing partnership and is well acquainted with SCAN's commitment to CaIifomia's seniors and adults with disabilities. Because of this, the Los Angeles Department of Aging supports their inclusion in CaIifomia's Dual Eligibles Demonstration Program. lf you need any additional infonnation, please do not hesitate to contact me. - SincerelyLos Angeles City Area Agency on Aging . plan g> AN EQUAL EMPLOYMENT OPPORTUNITY - AFFIRMATIVE ACTION EMPLOYER County of Los Angeles CHIEF EXECUTIVE OFFICE Kenneth Hahn Hall of Administration 500 West Temple Street, Room 713, Los Angeles, California 90012 (213) 974-1101 http://ceo .Iacou nty.gov WILLIAM T FUJIOKA Chief Executive Officer Board of Supervisors GLORIA MOLINA First District MARK RIDLEY-THOMAS Second District February 21,2012 ZEV YAROSLAVSKY Third District DON KNABE Mr. Toby Douglas, Director Fourth District Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: MICHAEL D. ANTONOVICH Fifth District are successful in their bid for California's Dual Eligible Demonstration Request for Solutions. As Chief Executive Officer of the County of Los Angeles, I have executive I am writing to express our commitment to collaborating with SCAN Health Plan if they authority over most County departments and operations, including the Departments of Health Services (DHS), Mental Health (DMH), Public Social Services (DPSS), which administers the In-Home Supportive Services (IHSS) program, and Community and Senior Services (CSS), which includes the Area Agency on Aging. We understand that the goal of the Dual Eligible Demonstration is to develop a model which provides greater care coordination for Medicare and Medicaid "dual eligible" seniors and disabled that will help improve beneficiaries' quality of life and potentially yield savings. Dual eligible seniors have specific needs that can only be met by tested and experienced plans. The best way to approach success in each county is through collaboration. As a current contractor with CSS, SCAN currently administers the Older American Act, Title IIIB and IIIE programs, as well as Los Angeles County's Linkages Program demonstrating home and community-based experience that has been vital to our County. In addition to collaboration by CSS, the participation by DHS, DMH and DPSS will ensure that the medical, mental health, and supportive services provided by those respective agencies will be appropriately integrated into the planned implementation of the SCAN proposal for integrated services to the Dual Eligible population. ''To Enrich Lives Through Effective And Caring Service" Please Conserve Paper- This Document and Copies are Two-Sided Intra-County Correspondence Sent Electronically Only Mr. Toby Douglas February 21,2012 Page 2 Through CSS involvement with SCAN, we are well acquainted with their s commitment to California's seniors and disabled individuals. Because of this, we look forward to collaboration if they are selected as a California's Dual Eligibles Demonstration Program. If you have any questions regarding this letter of support, please contact Sheila Shima, at (213) 974-1160 or at sshima~ceo.lacounty.gov. Sincerely, WILL~ft WTF:SAS:hd Chief Executive Officer 022112_HMHS_LosAngelesCountyLetterScan_L I I II II I IFMIIE I I I Iwlm I Illomlaaouthland California Southland Gliaptar MII Halplina: l000) 272-3000 Los Angola: Office 323 939 3379 sauu awa., sm. 1100 323 asn mast LosAnqa|es.CA90036 alzhe1mer's Q5 association' February 13, 2012 Toby Douglas, Director California Department of Health Care Services - 1501 Capitol Avenue, MS 0000 - - P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, As the state of California seeks to enhance the care coordination provided to Medicare and Medicaid "dual eligible" seniors through enrollment in managed care plans, SCAN Health .Plan's distinguished record and commitment to Califomia's disabled and seniors make it an exemplary candidate. The Alzheimer's Association, Califomia Southland Chapter currently I serves on SCAN's Member Community Advisory Committee and is the Caregiver Services Representative. Our participation on this- Committee, as well as our cooperation with SCAN on case management, community outreach, and educational p1?ojects, give us a unique insight into how SCAN's involvement in the demonstration program could benefit dual eligibles and potentially yield savings. SCAN Health Plan plays a critical role in caring for Californians living with Alzheimer's disease. Its model of care extends far beyond medical coverage and encompasses vital home - and community-based services that help both patients and their caregivers. SCAN's broad-based . services recognize that individuals living with Alzheimer's span the continuum, with some . patients needing only periodic services while others require intensive and constant care. We are - . deeply gratified by SCAN's commitment to helping seniors live with independence and dignity - in their local communities and are very pleased to off`er our unconditional support for SCAN Health Plan's inclusion in California's Dual Eligibles Demonstration Program. The California Southland chapter of the Alzheimer's Association serves people with dementia, their family caregivers, and professionals in Los Angeles, Riverside, and San Bernardino Counties. Some of our key programsdesigned for family caregivers are: the website at with educational materials in both English and Spanish; the - - 24/7 telephone information and referral service known as Helpline; professional care consultants who assist caregivers by providing support, counseling and help connecting with needed services; caregiver and community education programs offered in a variety of languages and locations and to many different audiences; over 140 affiliated support groups conducted in five languages; the Medic Alert+Safe Ret1u?n identification program for individuals with memory loss; ComfortZone'm a GPS-based program for patients at-risk for wandering; and community the compassion to care, the leadership to conquer' FEDERAL TAX ID service development projects that targets under-served communities. Over 2,000 professionals . access our programs for training on Alzheimer's disease and its care each year. SCAN Health Plan's experience providing a range of services for seniors make them an excellent candidate for your California's Dual Eligibles Demonstration Program. If you have any questions regarding this letter of support, feel hee to contact me at 323-930-6225 or debra.cherry@alz.org. Sincerely, Debra Cherry, Executive Vice Presiden VCVVAriiu*-suf JE . . VVAAyu` ;om.V..hammghim .V.. A ..VVAVA .. .. . 'onVAgAEVAL Aj- Aggr lg") lv gl?AA1' ik 5. A . A.- gwV-., . .. All..-. - . -.- .. .. .. . . . .. .. 7 A GEM 1 tl ips, I 3 1 i. 5* hnimi ?i?!in ?ih?I lg kr ti l?1.d h1 i ki;. i ?i h; XIPQXQ isn ;h1??h 1* nIn|?? -1 - - - L- I Lx 1Q: I . lill? The Center for Aging Resources February 15, 2012 o Hehtage Clinic 447 N. El Molino Ave. Pasadena, CA 91101 (626) 577 - 8480 Fax (626) 577- 8978 301 N. Prairie Ave. Suite 612 Inglewood, CA 90301 (310) 673-8402 Fax (310) 673-8407 155 N. Occidental Blvd. Suite 243 Los Angeles, CA 90026 (213) 382-4400 Fax (213) 382-4494 1037 West Avenue N Suite 205 Palmdale, CA 93551 (661) 575-9365 Fax (661) 575-9502 1940 Market Street San Diego, CA 92102 (619) 233-3381 Fax (619) 236-8240 6160 Mission Gorge Rd. Suite 120 San Diego, CA 92120 (619) 282-2232 Fax (619) 282-2992 200 E. Washington Ave. Escondido, CA 92025 (760) 737-8642 Fax (760) 737-8918 The Community Assistance Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, Heritage Clinic, the mental health division of The Center for Aging Resources, supports the state of California's efforts to advance care coordination to better meet the complex needs of older and disabled adults who are dually eligible for Medicare and Medicaid. For more than 30 years, Heritage Clinic, based in Los Angeles County, has provided mental health services to diverse older adults with limited resources. Based on its substantial experience with elders who experience symptoms of mental illness, often complicated by chronic factors such as diabetes, pain, substance abuse and dementia, Heritage Clinic believes it is critical that the state partner with managed care plans that have demonstrated experience in working alongside elders whose needs are complex, such as dually eligible older adults. The SCAN Health Plan is one such plan. In addition to partnering with SCAN's Independence at Home division to coordinate elders' care management and mental health services in Los Angeles and San Diego Counties, Heritage Clinic also partners with SCAN as a member of its Member and Community Advisory Committee. Through these partnerships with SCAN, Heritage Clinic has found SCAN's model of care to be collaborative and responsive in providing thousands of seniors with much-needed medical care and essential home- and community-based services, services that are key to keeping seniors in their own homes and communities and out of institutions. As a step toward California successfully increasing care coordination for dually eligible elders, Heritage Clinic strongly supports the inclusion of SCAN Health Plan in California's Dual Eligibles Demonstration Program. As a private nonprofit agency that provides public mental health services for older adults in Los Angeles and San Diego Counties, The Center for Aging Resources' Heritage Clinic values SCAN Health Plan's geriatricfocused, innovative and collaborative approach. The SCAN Health Plan's approach complements Heritage Clinic's in-home delivery of the following mental health services: psychotherapy, clinical rehabilitative services, and Program for Seniors Alzheimer's Day Care Centers 3740 E. Sierra Mache Blvd. Pasadena, CA 91107 (626) 351-5427 Fax (626) 351-2308 520 South Larlz Ellen Ave. West Covina, CA 91791 (626) 917-4484 Fax (626) 917-4475 Website www.centerforagingresources.org a nonprofit agency outreach and engagement; care coordination; psychiatric assessment and prescriptions for medication; psychological assessment and assessment of clinical capacities (to inform decisions such as representative payee and daily money management); group therapy and support groups; peer support; community outreach and education; and professional training activities and education. In addition, SCAN Health Plan's demonstrated history of serving culturally and economically diverse older and disabled adults with personalized home- and community-based services (e.g., Independence at Home, Multi-purpose Senior Service Project [MSSP]) fits well with Heritage Clinic's long-standing commitment to assist elders with symptoms of mental illness to overcome barriers (e.g., economic, cultural, physical, cognitive, emotional) to services. In Los Angeles County, Heritage Clinic's clientele is comprised of diverse elders (e.g., Caucasian, 34%; Latino, 31%; African American, 17% and Asian, 2%), of whom more than 75 percent have low incomes. As Chief Executive Officer of Heritage Clinic, I am pleased to strongly recommend SCAN Health Plan's participation in California's Dual Eligibles Demonstration Program. The SCAN Health Plan's breadth of knowledge addressing the complex needs of older and disabled adults, and demonstrated history of community partnerships, qualify SCAN for inclusion in the program. If I may provide additional information, please contact me at 626-577-8480, extension 119, or at vkelartinian@heritageclinic.orq. Sincerely, I A (-A Vatche Kelartinian, MBA Chief Executive Officer The Center for Aging Resources February 15, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, The Mexican American Opportunity Foundation believes that all Californians deserve access to high-quality, affordable health care. For Medicare and Medicaid "dual eligible" seniors and disabled, it is critical that the State ensure that participating plans have the experience and cultural sensitivity to serve all Californians, including the Latino community. We believe that SCAN Health Plan should be included in California's Dual Eligibles Demonstration Program. As a Member of SCAN's Member & Community Advisory Committee and, specifically, the Committee's Cultural Needs Representative, the Mexican American Opportunity Foundation knows that SCAN's model of care serves the needs of elderly and disabled Latinos very well. SCAN provides not only much-needed medical care, but also important home and community-based services that help seniors stay in their own homes or with their families and not be forced into an institution. Such services include SCAN's "Classroom in the Community", a health education program tailored to help seniors control and improve their health. The Mexican American Opportunity Foundation has partnered with SCAN to bring this program to Spanish-speaking low income areas of Los Angeles County with hopes of better addressing the health needs of the Latino community. These services are critical to Latinos as they help individuals stay healthy and keep families intact. All seniors and disabled individuals deserve a caring and compassionate health care system and that is what SCAN Health Plan helps to advance. The Mexican American Opportunity Foundation (MAOF) is a non-profit, community based organization that was established in 1963 in order to serve disadvantaged individuals and families in the Los Angeles area. MAOF is the largest Latino-oriented, family service organization in the United States, and has achieved this status by providing high quality social services and programs to those communities where the need is greatest. MAOF service programs include, but are not limited to: Senior and disabled services (Handyworker, Home Secure, Senior Hispanic Information and Assistance Services), Family Caregiver Support Services, Child Care and Development Programs, Child Care Centers, state preschools, Head Start Centers and a network of child care providers Resource and Referrals, a Food Bank, Financial Literacy and computer literacy education. I strongly support SCAN Health Plan's participation in California's Dual Eligibles Demonstration Program as their comprehensive services have helped seniors remain healthy in their homes and communities. With any questions regarding this letter of support, please contact me at (323) 313-1605 or at ejimenez@maof.org. Sincerely, Elizabeth Jimenez Program Director Mexican American Opportunity Foundation (MAOF) . I r` i irrln - - ardens.iAR2(i ln! re_?2r??1 LH. wi February 15, 2012 Toby Douglas, Director California of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Nlr. Douglas, lp As California works to increase the qu'a|ity of care provided to Medicare and Medicaid 'dual e|igI|es' through better care coordination, the Human Services Association is pleased to support SCAN Health P|an's proposal to participate in the demonstration program. The success of this demonstration project rests with health plans that have the demonstrated expertise to care for complex populations such as duals and to work with a wide range of community-based organizations. Through my role as MSSP Site llector, I hve seen first hand horl expert clre coordination and medical care can promote home and community based living for our most frail and vulnerable seniors. SCAN's model of care spans the continuum and provides not only medical care, but essential home and community-based services that allow individuals to We independently within their corrju-rities. Hunln Services Association has been proviing comprehensive home and coimunity based services for over 40 years. HSA's services span the aging spectrum and provide meals at senior centers, meals at home, care management, home based care, A|zheimer's Day Care, careyver senrices, and general advocacy. We are proud to partner wir SCAN as we share a vision to provide quality long term stgort senrices for vulneralt senior citizens. SCAN Healtl Plan experience provioI1g an adequate range of services for seniors make them an excellent candidate for your California's Dual Eliibles Demonstration Program. I strongly lrpport their inclusion in the progral and am eager to partner with -- - ee11iOis,%1 nan nm; 1?au4u Willi them to help improve the net for the Los Angeles-area's frail and vulnerable seniors. With any questions regarding this letter of support, please contact me at 562-806-5400, or at Darren.dunaway@hsalatorg. Sincerelyrren Dunaway Associate Director JW . a` Multipurpose Senior Services Prog 1* (MSSP) Human Services Association in Huntington Hospital RO. Box 01 . . 91 109-7013 Development and Pubh: Agzm (626) asv-mr February 15, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas: As California seeks better care coordination for Medicare and Medicaid "dual eIigibIes" through its new demonstration project, Huntington Hospital Senior Care Network urges that you ensure contracts are awarded to proven, experienced health plans. With that in mind, and given the challenges in caring for dual eligibles, we are pleased to support SCAN Health Plan's application to be selected as a demonstration health plan provider. Huntington Hospital Senior Care Network (HSCN) provides an array of home and community based services for adults and older adults in the San Gabriel Valley of Los Angeles County. Since our beginning nearly 30 years ago, HSCN has gained experience and a strong reputation as a leader in providing home and community-based services including care management/care coordination, care transitions, community resource infonnation, health education, caregiver supports and services and comprehensive geriatric assessment services. Our team of social work and nursing professionals works closely with patients and their families, health care providers, community agencies, and staff of our own and other area hospitals in fulfilling our mission to maximize wellness and independence. We have many years experience as a Medi-Cal HCBS waiver provider of both the MSSP (site 16) and Assisted Living Waiver services. Toby Douglas, Director Page 2 SCAN's model of care shares the same vision and goals as our organization, as well as the demonstration project; we look forward to partnering with them to improve the access to high quality care integrated health and long term services and supports for CaIifornia's population of dual eligibles. Feel free to call me with any questions you may have regarding this letter of support or you may contact Eileen Koons, Director of Senior Care Network, at (626) 397-2011. Sincereg, JANE HADERLEIN Senior Vice President C: Chris Wing, Chief Executive Officer, SCAN Health Plan Timothy Schwab, Chief Medical Officer, SCAN Health Plan Eileen Koons, Director, Senior Care Network A family of services. A family that serves. ebruary 16, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, Jewish Family Service of Los Angeles (JFS) would like to offer our support for SCAN Health Plan's participation in Califomia's Dual Eligibles Demonstration Program. SCAN's mission and the program's stated goals are well-aligned. SCAN 's participation will help ensure the demonst1?ation's success by improving care coordination for Califomia's frail and vulnerable populations. Jewish Family Service of Los Angeles is a non-sectarian organization that has a long and continuous history of providing services to families and individuals in need. Since its inception in 1854, the agency has evolved into a multi-faceted, multi-service organization. Our mission is to strengthen and enhance individual, family, and community life by providing a wide range of services at every stage of the life cycle, especially to those who are poor and disadvantaged. JFS was one of the original pilot sites for the groundbreaking Multipurpose Senior Services Program (MSSP) which provides comprehensive, professional nursing, social work, and clinically driven direct services to the frailest elderly so they may remain safely at home. Through a statewide network of providers, MS SP has reduced overall health services costs while enhancing quality of life for medically fragile, nursing home-eligible seniors for more than 30 years. For over three decades, SCAN Health Plan has played a key role in helping to strengthen the safety net for Southern California's seniors and disabled. Working with hail and homebound seniors as an MSSP Site has allowed us to see the vital role expert care coordination plays in helping seniors live safely and with dignity in their own homes. With a model of care focused on meeting the individual's comprehensive needs -- not only medical, but also vital home and community-based services -- SCAN will help individuals live independently within their local communities. Phone: 323.761.88OO Fax: 323.761.8801 3580 Wilshire Blvd. Ste. 700 Los Angeles, California 90010 Jewish Family Service is a beneficiary of SCAN 's approach has helped seniors live richer and fuller lives with the quiet dignity that all individuals deserve, especially in the twilight of their lives. We are hopeful that SCAN will be selected to participate and look forward to parmering with them in California's Dual Eligibles Demonstration Program. If you have any question regarding this letter of support, please contact me at 323-761-8800 and pscastro@_ jfsla.org. Sincerely, Paul S. Castro Chief Executive Officer February 20, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Dear Mr. Douglas, The Partners in Care Foundation support the SCAN Health Plan playing an important role in California's Dual-Eligibles Demonstration Program. With more than three decades of experience providing medical and care coordination services for Southern California's seniors, SCAN Health Plan brings a unique depth of experience to caring for dual-eligibles. Their proven commitment to meeting the comprehensive needs of seniors includes medical and behavioral care as well as important personal care services like assistance with bathing, cooking, and cleaning. As the provider of three MSSP Sites, I understand well the role proper care coordination can play in fostering independent living and preventing the inappropriate placement of older adults in nursing facilities. SCAN's model of care fits MSSP's purpose well as it combines comprehensive medical services with home and community-based care that enable seniors to live safely in their own homes. We have two sites in Los Angeles County - covering from Long Beach north to the northern boundary of the County, and up through Antelope Valley. We operate a third site in Kern County. Our populations are very diverse and very frail. We are the largest provider of MSSP services in California, customizing care to a wide range of specific local communities and needs. I strongly support SCAN's participation in California's Dual Eligibles Demonstration Program and look forward to partnering with them to help strengthen the safety net for our most frail and vulnerable seniors. If you have any questions regarding this letter of support, please contact me at (818) 837-3775 or my email: jsimmons@picf.org. Sincerely, W. June Simmons, CEO 732 Mott Street, Suite 150 | San Fernando, CA | 818.837.3775 | www.picf.org February 14, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Re: SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions Dear Mr. Douglas, I am pleased to offer my perspective about SCAN Health Plan's application to participate in California's Dual Eligibles Demonstration Program. Better care coordination of California's Medicare and Medicaid "dual eligibles" is a worthy public policy goal and one that should be advanced only with capable and expert partners. SCAN Health Plan would be one such partner. As the founding director of the Care Transitions Program and the developer of our evidence-based Care Transitions Intervention, I have worked with SCAN for nearly a decade to help adapt and tailor this model to meet the complex care needs of its patient population. SCAN has proven to be a very innovative and dedicated organization seeking to help address patient care at every point on the health care continuum. SCAN's implementation of both the Care Transitions Intervention and its own model of care have provided better care coordination for its seniors, their family caregivers, and clinicians. In turn, these tools have enabled SCAN's enrollees to live independently within their local communities and help avoid costly institutional care. SCAN's model of care complements the demonstration's goals and I am enthusiastic about their participation. I would be more than willing to further elaborate on SCAN's commitment and innovation and hope you will favorably evaluate this application. Respectfully, Eric A. Coleman, MD, MPH Professor of Medicine Head, Division of Health Care Policy and Research Director, Care Transitions Program Eric.Coleman@ucdenver.edu Department of Geriatrics 1115 W. Call Street, Suite 4305 Tallahassee, Florida 32306-4300 Telephone: (850) 645-1513, FAX: (850) 645-2824 Web Site: http://www.med.fsu.edu/geriatrics THE FLORIDA STATE UNIVERSITY College of Medicine 2/22/2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Regarding: SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions Dear Mr. Douglas, As a physician specializing in geriatrics, and a former president of the American Geriatric Society, I am pleased to share my thoughts about SCAN Health Plan's application to participate in California's Dual Eligibles Demonstration Program. I have been a member of the Geriatric Advisory Board for SCAN for nearly ten years and have assisted them in using motivational interviewing to help their members think about advance care planning, including end-of-life care. I believe that SCAN would be an ideal partner for the demonstration program. With more than three decades of service to seniors in Southern California, SCAN has the requisite expertise to care for complex and vulnerable populations. I have been very impressed by SCAN's commitment to quality and innovation. The American health care system does a fairly good job of providing acute care, but too often fails to address seniors' expectations about chronic and long-term care and especially in end-of-life care. SCAN's participation in the program would help seniors address these inevitable questions. Further, given SCAN's record of helping seniors live independently in their local communities, SCAN would be well positioned to address advance care planning in a home or community-based setting. I urge you to consider their application positively and invite them to participate Sincerely, Our mission is to educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elder, rural, minority, and underserved populations. Kenneth Brummel-Smith, MD, ABFP, AGSF Charlotte Edwards Maguire Professor & Chair, Department of Geriatrics Our mission is to educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elder, rural, minority, and underserved populations. 11 1 1: 11 1 1- Bloomberg School ot Puhlle Health Department of Health Pollcy and Management 624 N. Broadway, Room 380 Baltlmore MD 21205-1999 410-502-3962 I Fax 410-955-0470 Gulded Dare February 15, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Regarding: SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions Dear Toby, As an expert in caring for seniors living with and managing chronic conditions, I have worked closely with SCAN Health Plan for nearly five years to help it design and implement effective health programs for this population. Based on my experience and given its record of performance, SCAN would be an ideal candidate for participation in California's Dual Eligibles Demonstration Program. My care management program, Guided Care, is a nationally recognized leader in providing health plans and other providers with comprehensive care tools and techniques for managing chronically ill seniors. SCAN 's staif has participated in our educational programs and has incorporated important lessons into their own care management programs. SCAN 's model of care builds on these lessons by helping to address the comprehensive needs of vulnerable populations. In doing so, SCAN helps its members live independently within their own communities and eijoy fuller and richer lives with their loved ones. I have no doubt SCAN would be an outstanding partner for this demonstration project, and I encourage you to select SCAN for your demonstration program. Professor Johns Hopkins Bloomberg School of Public Health 2/22/2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Regarding: SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions Dear Toby, As California seeks to expand the coordinated care options available to Medicare and Medicaid "dual eligibles," SCAN Health Plan has the expertise to play a pivotal role in advancing the goals of the demonstration project. With a complex population such as the dual eligibles, it is essential that the project only select those plans with the experience and know-how to care for low-income, frail seniors. As an outside expert advisor to SCAN, I have seen first-hand how SCAN's innovative model of care advances quality patient care, especially with the PACE program. SCAN has long incorporated evidence-based data into its programs and is open and willing to learning how new practices can work for its case management programs. After having worked with SCAN for nearly 10 years, I am confident that they would be an outstanding partner for the demonstration project and I urge their inclusion in the program. Sincerely, Cheryl Phillips, M.D. Senior VP Advocacy and Policy LeadingAge cphillips@leadingage.org UNIVERSITY OF MINNESOTA Twin Cities Campus Minnesota Chair in Long-Term Care and Aging Division of Health Policy and Management School of Public Health Mayo Mail Code 197 420 Delaware Street SE Minneapolis, MN 55455 Office Location: D-351 Mayo Memorial Building 612-624-1185 Fax: 612-624-8448 February 15, 2012 Toby Douglas, Director California Department of Health Care Services 1501 Capitol Avenue, MS 0000 P.O. Box 997413 Sacramento, CA 95899-7413 Regarding: SCAN Health Plan Response to California's Dual Eligible Demonstration Request for Solutions Dear Mr. Douglas: I would like to offer my perspective on SCAN Health Plan's participation in California's Dual Eligibles Demonstration Program. As a physician with expertise in long-term care and aging issues who has advised SCAN for nearly ten years and who has studied care for dual eligibles for more than two decades, I am well positioned to offer guidance about SCAN's ability to serve California's dual eligibles. I strongly recommend SCAN Health Plan for approval in the Demonstration Program. They have a strong commitment to this area of care and a long record of creative and effective services for this population. SCAN's participation in the program would benefit California's duals on multiple fronts. SCAN has a long history of case management, comprehensive geriatric assessment, and integration of home and community-based services and partnerships with community agencies. These integrated services meet the individual's needs across the care spectrum, well beyond just medical services. SCAN's model of care helps enable seniors to remain living in their own communities surrounded by loved ones and to avoid costly institutional care. By helping seniors to live with dignity, SCAN is fulfilling its mission and is poised to help the demonstration project succeed. Sincerely, Robert L. Kane, MD Professor I I II II I IFMIIE I I I Iwlm Comparison of SCAN Dual Eligibles versus California Fee-For-Service Dual Eligibles Preliminary Results from a study by Avalere Health, February 2012 (1) Patient Characteristic Total Sample Dual Eligibility Duals Months 2009 & Dual Months 2010 Zero Months & 1-6 Months Zero Months & 7-12 Months 1-6 Months & 1-6 Months 1-6 Months & 7-12 Months 7-12 Months & 1-6 Months 7-12 Months & 7-12 Months Mortality Number of enrollees who died in 2010 Mortality Rate Gender Female Male Age Groups 18-64 65-74 75-84 85+ Condition Groups (Percent of Enrollees) Bacterial infections Behavioral health and substance abuse disorders Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease (COPD) Cancer Diabetes Gastrointestinal disorders Hematologic disorders Major acute coronary events Musculoskeletal disorders Neurological disorders Other cardiovascular disorders Other conditions and factors influencing health care Other endocrine, immunity, and metabolic disorders Other ill-defined conditions and factors influencing health care 327 5.9% 3,858 1,726 4 2,372 2,388 820 58.3% 45.5% 19.7% 26.5% 25.7% 47.4% 48.9% 30.6% 3.7% 75.9% 78.0% 89.7% 69.1% 78.4% 79.6% 2,565 5.2% 28,443 20,551 15,813 14,990 12,530 5,661 49.5% 35.6% 12.5% 17.4% 18.4% 35.7% 42.2% 30.0% 2.8% 57.7% 56.0% 64.6% 41.6% 60.1% 57.8% SCAN Health Plan Duals 5,584 109 66 14 87 242 5,066 Medicare FFS Duals (CA only) 48,994 1,143 844 385 1,049 2,125 43,448 Patient Characteristic Other injuries and poisoning Other respiratory disorders Other urinary disorders Pneumonia Renal failure Skin disorders Stroke and TIA Traumatic injury HEDIS 30-day All-Cause Readmissions Rate 2010 Observed Readmission Rate ("Observed Rate") 2010 HEDIS Average Adjusted Probability ("Expected Rate") Ratio of Observed Rate to Expected Rate Prevention Quality Indicators (PQI) (Per 100,000 enrollees) Prevention Quality Indicator (PQI) Overall Composite Angina Without Procedure (PQI 13) Congestive Heart Failure (CHF) (PQI 8) Hypertension (PQI 7) Chronic Obstructive Pulmonary Disease (COPD) (PQI 5) Uncontrolled Diabetes (PQI 14) Diabetes Short-Term Complications (PQI 1) Diabetes Long-Term Complications (PQI 3) Lower-Extremity Amputation Among Patients With Diabetes (PQI 16) Dehydration (PQI 10) Bacterial Pneumonia (PQI 11) Urinary Tract Infection (PQI 12) Adult Asthma (PQI 15) (1) SCAN Health Plan Duals 34.7% 52.2% 56.7% 8.9% 31.9% 33.9% 12.4% 5.4% 15.0% 19.6% 0.76 4,996.4 429.8 1,325.2 250.7 734.2 0.0 0.0 197.0 0.0 232.8 1,056.6 644.7 125.4 Medicare FFS Duals (CA only) 29.3% 46.0% 42.9% 8.7% 12.5% 29.9% 9.6% 5.1% 19.5% 22.2% 0.88 5,908.9 83.7 1,539.0 128.6 832.8 51.0 112.3 555.2 110.2 228.6 1,081.8 826.6 359.2 The Avalere Health study com pared outcomes on the A HRQ Preve ntion Quality Indicators (PQI) Overall Composite and the HEDIS 30-day All-Cause Readmission Rate between Medicare FFS dual eligibles in California and dual eligib les enrolled in SCAN Health plan. The PQI Overall Composite m easures pote ntially avoi dable hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs), which are inten ded to reflect issu es of access to, and quality o f, ambulatory care in a given geogr aphic area. The analysis was conducted on a sam ple of SCAN Health Plan duals enrolled in SCAN's D-SNP plan for at least one month in 2010, but were continuously enrolled in SCAN He alth Plan for all of 2009 and 2010. Sim ilarly, Medicare F FS duals were identified as beneficiaries who were en rolled in Medi-Cal for at least one m onth in 2010. 2 I I II II I I IFMIIE I I I Iwlm HEALT 3800 Kilroy Airport Way Suite loo, P.O. Box 22616 Long Beach, CA 90801-5616 T E L 562 989.5100 FAX 562 989.5200 February 22, 201 2 Toby Douglas, Director California Department of Health Care Services 1507 Capitol Avenue P.O. Box 997413 Sacramento, CA 95899-741 3 Dear Mr. Douglas: This is a formal request for the State to keep confidential SCAN's Model of Care, submitted in full in Appendix 10 of our Request for Solutions filing for t h e Dual Eligible Demonstration. SCAN's Model of Care is described fully in the Project Narrafive section, and examples of our methodology are included in other areas of the Appendix. However, it is our strong position that the entire Model of Care is proprietary and confidential, and should be redacted when the entire submission is made public. As you bre aware, our Model of Care submitted for the Demonstration is based largely on SCAN'S Dual Eligible Special Needs Plan Model of Care. SCAN purticipates in a bidding process with other D-SNP applicants in the Medicare Advantage program, and publication of our Model of Care through the Demonstration could raise compefitiveness concerns. Thank you for consideration of this request. If you have any questions, please contact me directly ot 562-989-51 66. Sr. Vice President, cc: Chris Wing Peter Harbage General Counsel G:\Stoff Folders\Doug Iaques\Dual Eligible Pilot - 10s Angeles County\CA Duals Confidentiality Request 2-22-1 2.doc I I II II I I IFMIIE I I I Iwlm Case Management Guideline Screening and Prevention Name Brief Description of Guideline: Case mangers have an influential role in preventing disease and improving the health of the members. The preventive care guidelines presented here, are designed to assist care managers in coaching members and caregivers on the importance and recommended frequency of needed preventive services. This information may be of further assistance in the coordination of preventive care and health care decision-making with the primary care physician, and in achieving quality standards. The guidelines incorporate evidence based medicine (EBM), and clinical experience. Recommendations come primarily from two sources, the US Preventive Services Task Force (USPSTF), which is supported by the Agency for Healthcare Research and Quality (AHRQ), and the Assessing Care of Vulnerable Elders (ACOVE) project. USPSTF represents an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. The ACOVE project, conducted by RAND Health and Pfizer, Inc., developed a set of quality indicators for medical care of the elderly. Clinicians caring for older people face a number of barriers in implementing clinical guidelines. These barriers may include co-morbidities, frailty, dementia, end-of-life, and lack of social support. The guidelines also acknowledge the need to individualize evaluation and treatment approaches, taking into account the health status and preferences of older patients. For individuals who are severely demented or at end of life, most preventive screening should be suspended. Special Instructions on How to Use: The focus of this guideline is to identify the minimum standards for basic tests and screenings to promote health. .* Asterisks indicate that these are HEDIS, CAHPS, HOS measures. Definitions: ROBUST - Strong, healthy, functionally independent, no cognitive impairment. FRAILTY - Presence of under-nutrition, functional dependence, prolonged bed rest, pressure sores, gait disorders, generalized weakness, age > 90 years, weight loss, anorexia, fear of falling, dementia, hip fracture, delirium, confusion, going outdoors infrequently (homebound) and poly-pharmacy. Frailty significantly predicts disability and other adverse outcomes in older adults. END-OF-LIFE - May indicate multi-organ failure, functional dependence, hospice criteria met. Original Creator: Date : Reviewed By: Jodi Cohn Date: 01/2011 A Chopra, MD 04/2006 Page 1 of 6 INDEX I. Staying Healthy Indicators o o o o o o o Access to Primary Care Doctor Visits Advance Care Planning Breast cancer screening--Mammograms Cholesterol screening Colorectal cancer screening Elder Abuse Monitoring Immunization o flu o pertussis o pneumonia vaccine o shingles o tetanus Medication monitoring for long-term meds Mental Health-- Improving or Maintaining o Cognitive o Depression Osteoporosis Testing Physical Activity Monitoring o ADL/IADL functional status o Exercise Physical Health-- Improving or Maintaining o Weight o BP and orthostatic BP o Smoking o Hearing o ETOH/ Alcohol o Thyroid Stimulating Hormone (TSH) Women Only o Cervical/PAP smear o Pelvic only o Hormone replacement therapy Men Only o Prostate exam/Digital rectal o Prostate Cancer Screening PSA o Abdominal Aortic Aneurysm (AAA) screening if history of smoking o Visual acuity and glaucoma testing o o o o o o o II. Managing Chronic Conditions o o o Bladder control/Incontinence monitoring and improving control Diabetes care Managing Cardiovascular risk I. Controlling BP II. Aspirin III. Beta Blocker Osteoporosis management IV. Screening V. Treatment o Original Creator: Date : A Chopra, MD 04/2006 Page 2 of 6 Reviewed By: Jodi Cohn Date: 01/2011 Guideline Content: Robust Office Visits Medication Monitoring for Chronic Medications *HEDIS: -Annual Monitoring for Patients on Persistent Medications *HEDIS: -Care of Older Adults (SNP)-Medication review Colorectal Cancer Screening *HEDIS : Colorectal Cancer Screening At least annually At least annual evaluation for: o Geriatric non-recommended drugs (see attachment). o Specific drugs: ACE/ARB, digoxin, diuretic, anticonvulsants that require ongoing lab assessment. o Therapeutic duplication. o Potential drug/drug or drug/disease interactions. One or more of the following screenings: o Annual Fecal Occult Blood Test. o Flexible sigmoidoscopy every 5 yrs. o Colonoscopy every 10 years (exclusion: colorectal cancer or total colectomy. At least annually. Consider with evidence of cognitive impairment. At least annually, more frequently if symptomatic with or without treatment. As needed (1-4 times/yr) With each visit Frail Consider every 1 - 2 years. Not recommended for 85+. Cognitive Screening Depression Screening PHQ-2, PHQ-9 *HEDIS: Anti-depressant medication management Diabetes - *HEDIS: Comprehensive Diabetes Care2 See Diabetes Guideline if current diabetic Dx Hearing Impairment Weight Same Same Annual until age 75 with risk factors (hypertension, dyslipidemia, obesity): o HbA1c o Cholesterol o Blood Pressure Consider every 2 years BMI should be measured every 2 years until age 75. o Weight taken with each visit. If unintentional loss >5 -10 lbs./year, discuss eating pattern o Normal BMI-. BMI: 18.5 - 24.9;> 25 is obese: >30 is morbidly obese. Annual until age 75, with risk factors. Relaxed HbA1c <9.0=good control Annual evaluation as part of initial visit. Each visit, if able to weigh. *HEDIS-Adult BMI Assessment Original Creator: Date : A Chopra, MD 04/2006 Page 3 of 6 Reviewed By: Jodi Cohn Date: 01/2011 Robust Prescribing Aspirin as Primary Prevention of CV Events Cardio-Vascular Risk o If a history of MI or >2 cardiovascular risk factors including HTN, DM, dyslipidemia, obesity, or smoking. At least annual o BP target <140/90 or <130/90 with dx of diabetes, heart and renal disease. o Orthostatic BP if: symptomatic with dizziness or on antihypertensive or diuretic. Annual, if diabetic, cardiovascular disease or other risk factors (smoking, obesity, dyslipidemia). o All others every 1-2 years up to age 75. After acute MI: Treatment with BB for six months except if contraindicated or history of adverse reaction to BB therapy. Immunizations Annual Once; may repeat every 5 years for individuals with chronic diseases. Shingles-> 60 years of age, one time. Pertussis tetanus-diphtheria booster after age 49, Booster every 10 yrs. Primary series if has not received. o Same Frail BP and Orthostatistic BP: Orthostatic BP measures the change of BP with change in body position from lying to sitting to standing *HEDIS: BP Control Cholesterol Screening *HEDIS-Cholesterol management for patient w/ cardiovascular conditions. Post MI treatment *HEDIS: Beta Blocker (BB) after MI With each visit. Consider at least every 2 years. Same Influenza *CAHPS: Annual Flu Shot Pneumococcal *CAHPS: Pneumonia Shot Shingles Pertussis *CAHPS: Annual flu shot, *CAHPS: Pneumonia shot Annual Once; may repeat if greater than 5 years. Same Same Lifestyle Education: Exercise, Smoking Cessation, Alcohol Exercise/Activity Assessment at least annually. Recommendation: 30 minutes per day 5 times/week or 45 min every *HOS: Physical Activity other day. Smoking Cessation Assessment at least annually. If current smoker : o Advise to quit o Medication to support *CAHPS: Smoking Cessation cessation Recommend methods (i.e. website, support groups, medicines). Assess for misuse annually. Alcohol Misuse Target alcohol use at maximum: o Men - 2 drinks/day o Women - 1 /day (1-beer or 5 Original Creator: Date : A Chopra, MD 04/2006 & Injury Prevention Assessment at least annually. Encourage up to 30 minutes per day or as tolerated. Same Screen for any problem (abuse or safety concerns). Page 4 of 6 Reviewed By: Jodi Cohn Date: 01/2011 Robust oz wine or 1.5 oz per ETOH = a drink) Annually Frail Functional Assessment ADLs and IADLs *HEDIS: Care of Older Adults Elder Abuse Thyroid Stimulating Hormone(TSH) Urinary Incontinence *HOS measure: UI See Urinary Incontinence Guideline Visual Acuity and Glaucoma Testing *HEDIS: Glaucoma Screening Advance Care Planning *HEDIS: Care of Older Adults Osteoporosis ScreeningBaseline bone density testing Quarterly Each visit Annually Assess every 2 years unless symptomatic. Each visit Annually Same Assess every 2 years Glaucoma screening at least annually for > 65 yrs Annual Same Annual and as needed POLST if advanced illness or expected to die within 2 years. Same, not necessary after age 85. *HEDIS: Osteoporosis, within 6 months of fracture, bone density testing and Rx See Osteoporosis Guideline Breast Exam Breast Cancer Screening - Mammography *HEDIS: Mammography Cervical cancer screening - Pap smear All post-menopausal women, with any risk factor: Prior fracture after age 50, Family Hx Fracture, Hx Hip/Spine, low BMI, current smoking, glucocorticoid/steroid use > 3 months, Alcohol >2 drinks/day, Chronic Kidney Disease. Women Only Controversial, discuss with PCP. Every 2 years up to 74 years, unless at high risk. Not recommend for 75 years or older. Same Same, not recommended if less than 5 year life expectancy. If no cervix, no Pap necessary, (except if removed for malignant or premalignant condition). Stop screening at age 65 with 3 previous normal/negative Pap tests and no abnormal/positive cytology tests within last ten years. Original Creator: Date : A Chopra, MD 04/2006 Page 5 of 6 Reviewed By: Jodi Cohn Date: 01/2011 Robust If under 65, every 3 yrs if with 3 previous normal/negative Pap tests and no abnormal/positive cytology tests within last ten years. Pelvic Only No standard Frail Hormone Replacement - Hormone Replacement Therapy Prostate Cancer Screening Digital Rectal Exam Prostate Specific Antigen (PSA) - Lab Abdominal Aortic Aneurysm (AAA) Controversial discuss due to increased risk of breast CA. Encourage to discuss with MD. Men Only Annual <75 yrs: Controversial: Encourage member to discuss with MD 75+. Do not screen. One time ultrasound screening in men 65-75, with history of smoking. Same Annual Same Consider one time ultrasound screening in men 65-75 with history of smoking. References: US Preventive Services Task Force, http://www.uspreventiveservicestaskforce.org/ Wenger et al, Introduction to the Assessing Care of Vulnerable Elders-3 Quality Indicator Measurement Set, (2007). Journal of the American Geriatrics Society 55?S247-S252. Original Creator: Date : A Chopra, MD 04/2006 Page 6 of 6 Reviewed By: Jodi Cohn Date: 01/2011 Case Management Guideline Depression Name DESCRIPTION/PREVALENCE Depression is a serious health problem in older people, affecting approximately 19 million adults in the U.S. It is a medical disorder with genetic, biological, and psychological causes that is associated with pervasive low mood, loss of interest in usual activities, and diminished ability to experience pleasure. Identification and treatment can be more difficult in older people due to a variety of reasons: multiple chronic illnesses, medication side effects, impaired communication skills, numerous somatic complaints, and lack of time accorded to them in the clinical exam. Depression often remains unrecognized. SYMPTOMS Symptoms vary significantly: Some present with physical complaints or pain, while others may describe feeling sad, blue, unhappy, miserable, or down in the dumps. Early symptoms can include inability to sleep or sleeping too much, feelings of hopelessness, loss of appetite or eating too much, feeling easily angered or agitated and loss of interest in daily activities. These are usually present for two weeks or longer. RISK FACTORS The exact cause of depression is not known; many believe it is caused by chemical changes in the brain. Medical illnesses such as stroke, heart attack, cancer, Parkinson's disease, pain, and hormonal disorders can cause depressive illness. Alcohol or drug abuse can also precipitate depressive symptoms. Also, a serious loss, difficult relationship, social isolation, financial problems, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors are involved in the onset of a depressive disorder. PREVENTION Good preventive strategies include: Avoidance of illegal drugs or the inappropriate use of prescription drug (which can precipitate depressive symptoms), exercising, maintaining good sleep habits, volunteering or involvement in group activities that give pleasure, talking to a trusted friend or confidant, keeping in contact with positive, caring people. Recognizing and reporting early signs of depression to you doctor to start early intervention. TREATMENT PLAN Antidepressant medications and/or psychotherapy, especially in combination, can help. Cognitive-behavioral therapy with a professional has been found to be very effective in managing depressive symptoms or forms of talk therapy with trusted friend, clergy, or family member can improve mood. CASE MANAGER FOCUS ? Assess for depression and if depressed, assess for risk or warning signs of suicide ? Notify physician of any depression concerns ? Alert emergency support for suicidal threats with intent and plan ? Monitor and support adherence to treatment plan, especially following prescribed antidepressant regimen ? Facilitate physician follow up visit within 7 days of a behavioral health hospitalization Clinical Task and/or Assessment Findings All older people should be 1. Pre-Call Review to include: assessed for depression at ? Psychotropic medications least annually (or more often and/or clinical diagnoses if indicated). ? Compliance with ? Administer PHQ-2 to all medication regimen case management ? Prior behavioral health Guideline Original: Creator: S. Levine Date: 5/2006 Page 1 of 6 Case Manager Actions ? If the PHQ-2 is positive with a score greater than 3, or and/or member has a history of depression, or there is evidence of lack of adherence with medication/ treatment or other concern. a) Educate the member regarding benefits Updated: By: B. Kugelman/J.Cohn Date: 10/11 Guideline ? participants Administer the PHQ-9 if PHQ-2 is positive or there are concerns regarding depression, or suicidal thoughts or attempts Clinical Task and/or Assessment Findings admission events 2. Administer PHQ-2 with member only.) 3. Ask: Do you have a history of depression? Case Manager Actions (See Attachment A) 1. Administer PHQ-9 if PHQ-2 if greater than 3 Suicide Risk should be evaluated if suspected by positive depression screen; or statements made that cause concern. (See Attachment B- Risk Factors for Suicide) Original: Creator: S. Levine Date: 5/2006 1. Assess for suicide risk. If positive response to PHQ-9 Question #9--"Thoughts that you would be better off dead, or of hurting yourself in some way. " 2. Ask : b) Coach on the difference between "blues" (short term) versus depression (lasting longer than a few weeks), warning signs & symptoms and actions to take. c) Coach to Prevention activities (see Intro) d) Educate on the course of antidepressant treatment ? Initiation of treatment--medicine may need to be titrated to therapeutic dose. Monitor for affect and side effects. ? Response--may take up to 6 - 8 weeks. Dosage may be altered or new drug substituted if improvement not observed ? Maintenance--continue medications to prevent relapse. ? Discontinuation--is a decision member should make with their doctor based on history and risk for relapse. e) Send information from Healthwise(R) on depression, topics may include: ? What is depression? ? What causes it? ? How is it treated? Send PHQ-9 letter to physician if score >5, and advise member that information will be communicated. Call physician if there are any urgent or emergent concerns. ? Educate as needed on: medications, treatments, importance of adherence, signs and symptoms, when to call physician and self-care preventive activities. ? Send Healthwise(R) information on depression, if appropriate. Topics: ? Medicines ? Should I take an antidepressant? ? Side effects of anti-depressants ? Coach to schedule an appointment to physician to discuss the depressive symptoms and possible treatments. ? Schedule follow-up call to member to check status. ? Send Behavioral Health Consult Review, if additional information, resources or clarification, is needed. If positive findings and the member reports suicidal ideation, intent and/or plan or hopelessness about options, implement the following Protocol for Handling Suicidal Member: ? Remain on the telephone with the member Updated: By: B. Kugelman/J.Cohn Date: 10/11 Page 2 of 6 Guideline (See Attachment C - Warning Signs of Suicide in the Older Population) Clinical Task and/or Case Manager Actions Assessment Findings until help arrives at the member's home. ? Do you have the means? ? Enlist the aid of a peer case manager to make all the necessary telephone calls to 911 ? Have you thought about or PET team or the local police department, to a time and place? request a safety check. ? Do you see no other ? If member lives in a county with no PET team, options? the peer case manager should call either 911 or the telephone number for the local police or sheriff in the county in which the member lives. ? The peer case manager provides the local police or sheriff with all needed demographic information regarding the suicidal member. ? Remain on the telephone with the member until the first responders arrive at the residence. ? Offer a warm, caring, non-judgmental response to anything the member may verbalize. ? Be direct, talk openly and freely about the member's suicidal feelings ? Offer hope that there are alternatives and options, without discounting the member by stating: "You have so much to live for" or "You don't really want to die" ? When the police/PET Team or Sheriff arrives and the hand-off to the first-responders has been completed, the case manager may hang up the telephone and should document all findings and interventions in CCMS. ? Communicate all significant findings and interventions in a follow-up telephone call and/or letter to PCP. ? Follow-up with member upon discharge from ER or inpatient treatment to ensure aftercare appointments have been made or appointment(s) was kept. OR RESOURCES Healthwise(R) Resource: (SCAN Intranet>>For Employees>>Useful Links>>HealthWise Knowledgebase>> http://intranet/HealthWise/HealthwiseDisclaimer.asp (CTRL + left click) ? ? ? ? ? ? ? What is depression? What causes it? How is it treated? Medicines Should I take an antidepressant? Side effects of anti-depressants Suicide Thoughts or Threats References: Original: Creator: S. Levine Date: 5/2006 Page 3 of 6 Updated: By: B. Kugelman/J.Cohn Date: 10/11 American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010. IMPACT-Evidence-based Depression Care, http://impact-uw.org/ Original: Creator: S. Levine Date: 5/2006 Page 4 of 6 Updated: By: B. Kugelman/J.Cohn Date: 10/11 Depression Clinical Guideline Attachments Attachment A PHQ-2: 1. Over the past two-weeks, how often have you had little interest or pleasure in doing things? 2. Over the last two-weeks, how often have you felt down, depressed or hopeless? PHQ-9: Over the last 2-weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things that you usually enjoy. 2. Feeling down, depressed or hopeless. 3. Trouble falling asleep/staying asleep or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating. 6. Feeling badly about yourself or that you are a failure or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching the television 8. Moving or speaking so slowly that other people would have noticed, or the opposite-being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead, or of hurting yourself in some way. Assess PHQ-9 Score: ? ? ? ? 5-9 indicates Mild Depression 10-14 indicates Moderate Depression 15-19 indicates Moderately Severe Depression >19 indicates Severe Depression Note: The PHQ-9 score may not accurately reflect the severity of the depression or suicidal ideation, depending on the degree of member's understanding of the questions Original: Creator: S. Levine Date: 5/2006 Page 5 of 6 Updated: By: B. Kugelman/J.Cohn Date: 10/11 Depression Clinical Guideline Attachments Attachment B Risk Factors for Suicide: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. History of suicide in the family or prior attempt(s) by member. Chronic medical illness, including pain and functional impairment. Actively psychotic or severely depressed. Alcohol or substance abuse. Terminal illness. Social isolation, recent death of spouse. Financial difficulties. Hopelessness Non-Hispanic white males. Age over 65. Untreated & undiagnosed depression. Attachment C Warning Signs of Suicide in the Older Population: 1. 2. 3. 4. 5. 6. 7. Statements about death and dying. Rush to complete a will. Statements of hopelessness. Reading material about death and dying. Stockpiling medications. Overt or covert suicidal statements or threats. Sudden interest in firearms. Original: Creator: S. Levine Date: 5/2006 Page 6 of 6 Updated: By: B. Kugelman/J.Cohn Date: 10/11 Case Management Guideline Diabetes Name DESCRIPTION/PREVALENCE Diabetes is a chronic illness that requires continuing medical care and ongoing self-management and monitoring to prevent acute complications and to reduce long term risks caused by elevated blood glucose (sugar) which can harm eyes, kidneys, nerves, skin, heart, and blood vessels. Diabetes is an important health condition for the aging population; at least 20% of patients over the age of 65 years have diabetes. The older adults with type 2 diabetes may have a wide range of clinical and functional differences in diabetes duration, complications, physical and cognitive capability, and life expectancy. SYMPTOMS Include increased urination and thirst, weight loss, excessive appetite (especially after eating), unexplained weight loss, blurred vision, headaches, extreme fatigue and irritability, frequent infections (recurring skin, gum, or bladder infections), cuts or bruises that are slow to heal, skin disorders , tingling/numbness in the hands/feet, and loss of consciousness (rare). RISK FACTORS Include having a first-degree relative with diabetes; adults who are overweight having a BMI >=25 kg/m?); certain race/ethnic groups (e.g., African American, Latino, Native American, Asian American Pacific Islander); women who delivered a baby weighing >9lb or were diagnosed with gestational diabetes. Having a high BMI along with other risk factors further increases the risk of developing diabetes. PREVENTION Emphasis on life style changes that include, moderate weight loss (7% body weight) and regular physical activity with dietary strategies to reduce calorie intake and dietary fat and adding dietary fiber (14g fiber/1,000 kcal) and whole grains can reduce the risk for developing diabetes. TREATMENT PLAN Treatment plan should include a collaborative therapeutic alliance among the patient and family, the physician and other members of the health care team. Any plan should recognize self-monitoring of blood glucose, individualized meal plan and individualized medication therapy. Older adults who are functional, cognitively intact and have a significant life expectancy should receive diabetes care using the same goals developed for younger adults. If the older adult does not meet this criteria their glycemic goals may be relaxed. Also, the various screening activities may be relaxed for the older adult, but hyperglycemia leading to acute hyperglycemic complications should be avoided. The primary attention should be to avoid complications that would lead to functional impairment. CASE MANAGER FOCUS ? Assess level of knowledge and provide diabetes education and/or refer to program. ? Support self-management and adherence to treatment plan to avoid long term risks. ? Alert healthcare provider of possible deviations to the treatment plan. ? Educate on urgent vs. emergent signs and symptoms and actions to take. Guideline Adults over the age of 45 yrs with risk factors for diabetes or if BMI =>25 Kg/m2; should be screened annually for diabetes. All people with diabetes should receive Diabetes SelfManagement Education. Clinical Task and/or Assessment Findings 1. Are Blood glucose (BG) tested annually? Case Manager Actions ? Coach to discuss with PCP and screen for risk factors and complications of diabetes. ? Educate on risks associated with poorly managed diabetes. ? Refer for diabetes education as appropriate. ? Educate on diabetes monitoring and screening to prevent complications of diabetes. ? Diabetics have a high risks of developing Reviewed/ Revised: By: L. Gallegos Date: 10/2011 Page 1 of 4 1. Assess member/ caregiver current level diabetes education. 2. Is there a basic level of understanding regarding Original: Creator: R. Brower Date: 6/2006 Guideline Clinical Task and/or Assessment Findings diabetes selfmanagement and routine screening? 3. Does member/caregiver understand signs & symptoms of condition and actions to take? Case Manager Actions heart disease and should follow CAD guidelines that include smoking cessation, regular physical activity, a health diet, stress management (See CAD/Angina Guideline for ? Coach and support lifestyle changes and selfmanagement. (See Attachment A - Diabetes ? Educate on sign & symptoms of hypoglycemia and actions to take: ? Signs & symptoms: ? rapid heart beat ? perspiration ? shakiness ? anxiety ? confusion ? Actions to take: ? Call 911--if unconscious or suddenly confused. ? Call Doctor--if BG >300 or higher if instructed by MD, sick and having trouble controlling BG, vomiting or diarrhea >6hrs. Problems with consistent high or low BG levels.(See Attachment A-Diabetes Guideline for SelfManagement--hypoglycemia) Guidelines For Self Management ) more information) Self-monitoring of blood glucose for those using insulin (multiple dose/or pump) should be done at up to 3 to 4 times per day, or as ordered by their PCP. NOTE: ? Other people with diabetes on single-dose insulin, oral medications or diet-controlled; may find blood glucose monitoring helpful, selfmonitoring may be ordered. ? All insulin-dependent people with diabetes should be knowledgeable on blood glucose selfmonitoring and have monitor to assess for hypoglycemia as needed. Blood glucose control not achieved with weight loss, diet, and exercise may require medication therapy. Original: Creator: R. Brower Date: 6/2006 1. Does member selfmonitor blood glucose as directed? Recommendations for selfmonitoring: Robust Adult: ? On insulin (multiple injections)--3+ times/day ? On oral hypoglycemics, single dose insulin or diet controlled-- as ordered by PCP. Note: Target BG-results should be >60 but<140. Frail older Adult: ? On insulin regimen, check 2 - 4 times/day or as ordered by MD Note: Target BG- results >110 or <180. 1. What are self-reported BG results? 2. Are they outside of normal range? ? Educate on benefits of BG testing: ? Helps assess the effectiveness of the management plan ? Promotes self-awareness. ? Frequency and timing of BG testing should be dictated by the individual needs and goals of the member ? If frail older adult and not on insulin, may discuss necessity with PCP. ? Encourage patient to keep a log of BG results to take to the MD each visit ? Coach to discuss BG monitoring with PCP and obtain recommendation. ? Alert physician as needed for problems. ? Educate on treatment modalities: lifestyle modification, oral medications (single or combo), and insulin. Reviewed/ Revised: By: L. Gallegos Date: 10/2011 Page 2 of 4 Guideline Diabetes requires continuing medical care and ongoing selfmanagement and monitoring to prevent acute complications and to reduce long term risks caused by elevated blood glucose (sugar). Glycated hemoglobin (HgA1C)--check at least two times/year or more frequently if not achieving stable glycemic control. Control to reduce micro vascular complications Targets: HgA1C levels should be as close to 7% as possible Target ? Robust Adult - <7% is good ? Frail Older Adult - <8% or a more relaxed target, especially if history of severe hypoglycemia, or advanced disease. Blood Pressure (BP)-- Measure at each visit. Control to lower risk of stroke, heart disease, renal failure, and macro-vascular damage. Target BP for diabetics: ? Robust Adult - <130/80 Clinical Task and/or Assessment Findings 3. Does treatment plan include medications? Assess for problems with adherence or use of geriatric inappropriate meds. Note: Diabinese (Chlorpropramide) should not be used with older adults. 1. Does member have routine monitoring? ? HgA1C ? BP ? Lipids ? Retinal Eye Exam ? Renal function 1. What is HgA1C? Case Manager Actions ? Educate on medication compliance and the importance of taking meds as prescribed. ? Instruct on importance of regular lab test and monitoring to prevent complications of diabetes. ? Focus on the following indicators: ? Educate on importance of blood glucose control to prevent or delay diabetes-related complications. ? Coach to discuss HgA1C with physician 1. What is recent BP? 2. Does member monitor routinely? ? Coach on modifiable risk factors for hypertension; lifestyle therapies; diet, weight loss, moderate ETOH, increasing exercise, smoking cessation. ? Encourage to take the antihypertensive medications as prescribed ? Should be on ACE or ARB if no history of renal disease/side effects ? Might require multiple med treatment to control ? Alert PCP for uncontrolled BP or barrier to adherence of current treatment plan. ? Educate the importance of lipids control. ? Lifestyle modification w/ focus on diet low fat/low cholesterol and low CHO, and weight loss ? Lipid management w/medication therapy ? Registered Dietitian referral ? Coach to discuss with physician Reviewed/ Revised: By: L. Gallegos Date: 10/2011 See HTN Guideline for more information Lipid Profile--annual, may be semi annual if stable. Control to lower risk of heart disease, stroke, macro vascular damage Targets: Robust Adult-? Total Cholesterol <200 Original: Creator: R. Brower Date: 6/2006 1. Are lipids monitored routinely? Page 3 of 4 Guideline HDL >50 mg/dl LDL <100 mg/dl Triglycerides <150 mg/dl Other values per discretion of PCP if comorbid conditions. ? Frail Older Adult--Total cholesterol <240 Retinal Eye Exam--annually. Control to prevent or slow retinopathy and blindness. ? ? ? ? Clinical Task and/or Assessment Findings Case Manager Actions (See CAD/Angina Guideline for more information) 1. Dilated and comprehensive eye examination by an ophthalmologist or optometrist annually 1. Annual test to assess urine spot microalbumin excretion with duration of 5 yrs with diabetes? 2. Annual serum creatinine level to assess Renal function should be monitored at least annually. Diabetic nephropathy occurs in 20-40% of people with diabetes and is the single leading cause of end-stage renal disease. ? Refer to PCP for referral to specialist to assess for: ? Severe Non-proliferative Diabetic Retinopathy (NPDR) ? Proliferative Diabetic Retinopathy (PDR) ? Macular edema. ? Educate the importance of controlling BP and BG to prevent the progression of micro and macro albuminuria which leads to nephropathy. ? Educate on the need to incorporate an ACE or ARB to delay the progression of CKD ? Coach to discuss evidenced-based therapies with PCP as appropriate. See CKD Guideline for more information RESOURCES: Healthwise(R) Resource: http://intranet/HealthWise/HealthwiseDisclaimer.asp (CTRL + left click) ? ? ? ? Prediabetes Type II Diabetes Sick Day Guidelines for Diabetes Taking Care of Your Feet Travel Tips OR (SCAN Intranet>>For Employees>>Useful Links>>HealthWise Knowledgebase>>Diabetes ? References: The Journal of Clinical and Applied Research and Education Diabetes Care, January 2010 Volume 33, Supplement 1 Standard of Medical Care in Diabetes - 2010 by American Diabetes Association pages S 11 thru S 61 Supplement 1 www.Diabetes.org/diabetescare The Journal of Clinical and Applied Research and Education Diabetes Care January 2011, Volume 34, Supplement 1 American Diabetes Association: Clinical Practice Recommendations 2011 Standards of Medical Care in Diabetes - 2011 by American Diabetes Association pages S 11 thru S 61 www.Diabetes.org/diabetescare Wenger et al, Introduction to the Assessing Care of Vulnerable Elders-3 Quality Indicator Measurement Set, (2007). Journal of the American Geriatrics Society 55?S247-S252. Healthwise (R) Knowledgebase Diabetes Original: Creator: R. Brower Date: 6/2006 Page 4 of 4 Reviewed/ Revised: By: L. Gallegos Date: 10/2011 In the Clinic Hip Fracture Screening and Prevention Diagnosis and Evaluation Treatment and Management Patient Education Practice Improvement Tool Kit Patient Information CME Questions Physician Writers Fernanda Porto Carriero, MD Colleen Christmas, MD Section Editors Deborah Cotton, MD, MPH Darren Taichman, MD, PhD Sankey Williams, MD page ITC6-2 page ITC6-5 page ITC6-8 page ITC6-12 page ITC6-13 page ITC6-14 page ITC6-15 page ITC6-16 The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and SelfAssessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing divisions and with the assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org, http://www.acponline.org/products_services/ mksap/15/?pr31, and other resources referenced in each issue of In the Clinic. CME Objective: To review current evidence for the prevention, diagnosis, and treatment of hip fracture. The information contained herein should never be used as a substitute for clinical judgment. (C) 2011 American College of Physicians In theClinic H ip fracture is the most serious consequence of osteoporosis. About 1% of all falls in the elderly residing in the community result in hip fracture, often with life-changing consequences. Acute mortality from hip fracture is 3%-5%; the lifetime risk for death from hip fracture is similar to that from breast cancer. Far fewer than half of patients with hip fracture fully recover their ability to perform all of their basic activities of daily living. Outcomes are even more grim for those who have postoperative complications. Timely diagnosis and highly attentive perioperative care of the complex patient with a hip fracture aim to reduce the risk for such complications and to facilitate rapid transition to rehabilitation in the hopes of improving functional recovery. Screening and Prevention What medical comorbid conditions increase the risk for falls and hip fracture? Comorbid conditions that increase the risk for falls include advanced age (older than 75 years), sensory impairments (such as hearing or vision loss), conditions that cause gait instability or abnormal proprioception, depression, muscular weakness, orthostatic hypotension, and impaired cognition. The use of >=4 medications on a long-term basis, alcohol, and benzodiazepines can also increase the risk for falls (1, 2). Osteoporosis increases the patient's risk for hip fracture when a fall occurs. Patients should be evaluated for risk for osteoporosis by eliciting historical risk factors for osteoporosis. Certain patients with risk factors should undergo bone densitometry. Risk factors include history of fracture, glucocorticoid use, family history of fracture, cigarette smoking, excessive alcohol consumption, and low bodyweight (3). What are the mechanical risk factors for hip fracture? Gait instability, foot deformities, and environmental hazards in the home all pose mechanical risks for fall. Patients with a history of or risk factors for falls should undergo interventions to reduce the risk for falls and fractures. Begin with an evaluation for risk factors, which should include a review of medications; review of home safety 1. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332:767-73. [PMID: 7862179] 2. Zuckerman JD. Hip fracture. N Engl J Med. 1996;334: 1519-25. [PMID: 8618608] 3. Sambrook P, Cooper C. Osteoporosis. Lancet. 2006;367:2010-8. [PMID: 16782492] 4. 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. Accessed at www.medcats.com/ FALLS/frameset.htm on September 29, 2011. 5. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk for falling among elderly people living in the community. N Engl J Med. 1994;331:821-7. [PMID: 8078528] 6. Chang JT, Morton SC, Rubenstein LZ, et al. Interventions for the prevention of falls in older adults: systematic review and metaanalysis of randomised clinical trials. BMJ. 2004;328:680. [PMID: 15031239] (such as ensuring highly trafficked pathways are well lit and clear of clutter); a detailed history of falls; and testing of muscle strength, balance and gait, and neurologic function (particularly cerebellar function, proprioception, vision, and hearing). Interventions should then be targeted at reducing or eliminating risk factors. Patients with multiple risk factors are at highest risk and probably need a review of their calcium and vitamin D intake, medication adjustment (including pharmacotherapy for osteoporosis and reduction of polypharmacy), smoking cessation, balance training, environmental safety evaluation, and strengthening exercises to reduce their risk for fracture (1). Refer to The American Geriatrics Society published clinical practice guidelines for the prevention of falls in the elderly (4). Interventions to eliminate risk factors (Table 1) (including medication adjustment, exercise, and behavioral modification) significantly reduced falls in a community of older people (5). This finding was also supported in a metaanalysis (6). What is the role of bone densitometry in assessing risk for hip fracture? Bone densitometry is a valid method to diagnose osteoporosis (C) 2011 American College of Physicians ITC6-2 In the Clinic Annals of Internal Medicine 6 December 2011 Table 1. Interventions to Eliminate Risk Factors for Hip Fracture Risk Factor Intervention FRAX: WHO Fracture Risk Assessment Tool o o o o o Age Sex Weight Height History of previous fracture in adult life occurring spontaneously, or a fracture arising from trauma that, in a healthy individual, would not have resulted in a fracture. Parent fractured hip Current smoking Glucocorticoid use Rheumatoid arthritis Secondary osteoporosis--disorders strongly associated with osteoporosis, such as type 1 diabetes, osteogenesis imperfecta, untreated hyperthyroidism, hypogonadism, premature menopause, chronic malnutrition or malabsorption, and chronic liver disease. 3 or more units/day of alcohol BMD Age >75 Sensory impairment Gait instability Foot deformities Use of >=4 chronic medications Use of alcohol Use of benzodiazepines Environmental hazards in the home Depression Muscular weakness Orthostatic hypotension Impaired cognition Vision correction, hearing aids Physical therapy, assistive devices, strength and balance training Surgical correction, orthotic devices Elimination of nonessential medications Counseling to reduce or discontinue alcohol Reduction or discontinuation of benzodiazepines Ensure adequate lighting, install handrails in the bathroom and on the stairs, remove loose cords and rugs, store the most frequently used items in the kitchen within easy reach Evaluation and treatment of depression Physical therapy, exercise Behavioral modification (e.g., rising slowly from bed), reduction or elimination of medications that may worsen condition Evaluation and treatment for dementia and for reversible causes of cognitive decline o o o o o o o and to predict the risk for fracture. The fracture-risk assessment tool (FRAX) (see the Box) integrates risk factors with bone densitometry measurement to predict 10-year risk for sustaining hip fracture. Factors that are most highly predictive of an osteoporotic fracture are a history of previous low-impact fracture and low bone mineral density (BMD) (7). A meta-analysis showed that a 1-SD decrease in bone mineral density at the femoral neck was associated with a relative risk for hip fracture of 2.6 (8). A prospective study of 4124 women aged 65 years or older found that neither repeated BMD measurement nor change in BMD after 8 years was more predictive of subsequent fracture risk than the original measurement. It may be useful, however, to rescreen patients if there is clinical suspicion for greater-than-average acceleration of BMD loss (10). Adapted from FRAX calculation tool Web site: www.sheffield.ac.uk/FRAX/tool.jsp. How often should bone densitometry be performed? The U.S. Preventive Services Task Force has updated its screening recommendations for osteoporosis to women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. At this time, the U.S. Preventive Services Task Force does not make recommendations regarding screening intervals. Repeated screening has not been shown to be more predictive of subsequent fracture than the original screening measurement (9). What pharmacologic interventions can prevent hip fracture? Patients with known osteoporosis or risk factors for osteoporosis should be treated to prevent hip fracture. Effective therapies exist that have been shown to reduce fractures in both men and women with osteoporosis. Antiresorptive agents: calcium and vitamin D Inadequate intake of calcium and vitamin D leads to reduced calcium absorption, causing an increase in parathyroid hormone and subsequent increased bone loss. Vitamin D deficiency is also linked to reduced muscle function and higher risk for falling (3). A meta-analysis of randomized, controlled trials (RCTs) showed that, compared with calcium or placebo, a vitamin D dose of 700-800 IU/d reduced the relative risk for hip fracture by 26% (11). 7. Rachner TD, Khosla S, Hofbauer LC. Osteoporosis: now and the future. Lancet. 2011;377:1276-87. [PMID: 21450337] 8. Marshall D, Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254-9. [PMID: 8634613] 9. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011;154:356-64. [PMID: 21242341] 10. Hillier TA, Stone KL, Bauer DC, et al. Evaluating the value of repeat bone mineral density measurement and prediction of fractures in older women: the study of osteoporotic fractures. Arch Intern Med. 2007;167:15560. [PMID: 17242316] 11. Bischoff-Ferrari HA, Willett WC, Wong JB, et al. Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA. 2005;293:2257-64. [PMID: 15886381] 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-3 (C) 2011 American College of Physicians A follow up meta-analysis looked at RCTs of oral vitamin D with or without calcium supplementation. Results suggested that oral vitamin D reduces risk for hip fracture only when supplemented with calcium (12). 12. Boonen S, Lips P, Bouillon R, et al. Need for additional calcium to reduce the risk for hip fracture with vitamin d supplementation: evidence from a comparative metaanalysis of randomized controlled trials. J Clin Endocrinol Metab. 2007;92: 1415-23. [PMID: 17264183] 13. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE, Staehelin HB, Orav EJ, et al. Prevention of nonvertebral fractures with oral vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Intern Med. 2009;169:551-61. [PMID: 19307517] 14. Sanders KM, Stuart AL, Williamson EJ, et al. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010;303: 1815-22. [PMID: 20460620] 15. Abrahamsen B, Eiken P, Eastell R. Proton pump inhibitor use and the antifracture efficacy of alendronate. Arch Intern Med. 2011; 171:998-1004. [PMID: 21321287] 16. Manson JE, Hsia J, Johnson KC, et al; Women's Health Initiative Investigators. Estrogen plus progestin and the risk for coronary heart disease. N Engl J Med. 2003;349:523-34. [PMID: 12904517] 17. Prentice RL, Chlebowski RT, Stefanick ML, et al. Estrogen plus progestin therapy and breast cancer in recently postmenopausal women. Am J Epidemiol. 2008;167: 1207-16. [PMID: 18372396] 18. Ferrari S, Nakamura T, Hagino H, et al. Longitudinal change in hip fracture incidence after starting risedronate or raloxifene: an observational study. J Bone Miner Metab. 2011;29:561-70. [PMID: 21225297]. Selective estrogen-receptor modulators: raloxifene and risedronate The form and dose of vitamin D are a matter of debate. A meta-analysis of randomized trials suggested significant fracture reductions with higher doses of vitamin D administered and higher levels of serum 25-hydroxyvitamin D achieved in both community-dwelling and institutionalized older individuals (13). Selective estrogen-receptor modulators have been studied in numerous trials and have been shown to have a beneficial effect on vertebral fractures but not nonvertebral fractures in patients with osteoporosis. However, these drugs do increase the risk for venous thromboembolism (3). A large observational study evaluated women 65 years and older initiating either risedronate or raloxifene therapy. Women in the risedronate group had more risk factors for fracture at the time therapy was started. The study found that risedronate treatment in adherent patients rapidly decreased the risk for hip fractures, whereas raloxifene treatment did not (18). However, very high doses of vitamin D have been shown to increase the risk for falls and fractures compared with placebo. An RCT of 2256 community-dwelling women at high risk for fracture were assigned to receive 500 000 IU of cholecalciferol or placebo each autumn to winter for 3-5 years. Results showed that high-dose cholecalciferol resulted in an increased risk for falls and fractures compared with placebo (14). Anabolic therapy: parathyroid hormone and strontium renelate Bisphosphonates: alendronate, risedronate, ibandronate, and zoledronic acid Bisphosphonates inhibit osteoclastic bone resorption and have been shown to reduce the risk for hip fractures in women with osteoporosis. Clinical trials of bisphosphonate therapy show reductions in risk for nonvertebral fracture, including hip fracture, of 20%- 40% (3). A recent study showed a significant dosedependent loss of protection against hip fracture in patients receiving alendronate and a proton-pump inhibitor (15). Parathyroid hormone stimulates bone formation and has been shown to decrease the risk for vertebral fractures. However, the evidence is less strong for its benefits in reducing hip fractures. Parathyroid hormone therapy is limited to 2 years because of concerns for long-term safety (19). Strontium ranelate seems to simultaneously increase bone formation and decrease bone resorption, thus uncoupling the bone remodeling process. Data support the efficacy of strontium ranelate for the reduction of vertebral fractures (and to a lesser extent nonvertebral or hip fractures) in postmenopausal osteoporotic women over a 3-year period. Strontium ranelate increases the risk for diarrhea (20). Calcitonin Hormone replacement therapy: estrogen Estrogen has been shown to prevent a decrease in BMD. However, this therapy is associated with several health risks, such as breast cancer, coronary artery disease, stroke and thromboembolism. Therefore, it is not considered first-line therapy in management of postmenopausal osteoporosis (3, 16, 17). Calcitonin decreases bone resorption and has been approved for treatment of osteoporosis. It is, however, less potent than other antiresorptive therapies and has not been shown to reduce hip fracture and therefore is not considered first-line therapy for treatment of osteoporosis (21). (C) 2011 American College of Physicians ITC6-4 In the Clinic Annals of Internal Medicine 6 December 2011 Monoclonal antibody: denosumab Denosumab is a monoclonal antibody that inhibits development and activity of osteoclasts, decreasing bone resorption and increasing bone density. It has been approved by the U.S. Food and Drug Administration for treatment of osteoporosis in postmenopausal women at high risk for fracture. Although generally welltolerated, diarrhea, nausea, and achiness have been noted in about 1 in 5 women receiving this therapy. Calcium and phosphate levels must also be monitored during therapy. An RCT of 7868 women with a BMD T score less than -2.5 but not less than -4.0 at the lumbar spine or total hip were assigned either denosumab or placebo every 6 months for 36 months. Results showed that denosumab reduced the risk for hip fracture with a cumulative incidence of 0.7% in the denosumab group vs. 1.2% in the placebo group (hazard ratio, 0.60; 95% CI, 0.37-0.97; P = 0.04), indicating a relative decrease of 40% (22). exercise programs demonstrate a nonsignificant trend toward hip fracture reduction (24). A meta-analysis of the Frailty and Injuries: Cooperative Studies of Intervention Techniques study found that exercise, particularly with balance training or t'ai chi, reduces the risk for falls (25). Can home safety evaluations prevent hip fracture? The American Geriatrics Society has published clinical practice guidelines for the prevention of falls in the elderly. Their recommendations include a home environment assessment and intervention carried out by a health care professional for older people who have fallen or have risk factors for falls (4). Hip fractures often occur after falls, but there has been controversy over the effectiveness of home safety evaluations. A meta-analysis of randomized trials found that home assessment interventions can reduce falls by 39% among populations at high risk for falls (26). What is the role of exercise in preventing hip fracture? Risk factors for falls and fractures include physical inactivity, inability to rise from a chair without using the arms, gait instability, and lower-extremity weakness. Exercise can reduce the risk for falls and fractures in appropriate patients. The Study of Osteoporotic Fracture trial showed that exercise reduced the risk for hip fracture by 33% (23). Home-based Can hip protectors prevent hip fracture? The results of a recently updated Cochrane review suggest that the effectiveness of hip protectors in reducing hip-fracture risk in elderly people is still not clearly established. Hip protectors may reduce the risk for hip fracture in nursing home residents but not in community dwelling elderly people. Compliance is poor (27). Screening and Prevention... Risk assessment tools, such as FRAX, which combine identification of risk factors for falls and bone densitometry, can predict the 10year risk for sustaining hip fractures. Interventions aimed at eliminating risk factors, as well as pharmacologic therapies for osteoporosis (such as vitamin D and calcium supplementation, bisphosphonates, and monoclonal antibodies), have been shown to reduce the risk for hip fractures. CLINICAL BOTTOM LINE What is the differential diagnosis of hip fracture? A careful history and physical examination usually distinguishes a hip fracture from other disorders that present as pain in the hip area. Differential diagnosis includes referred pain from lumbar spine Diagnosis and Evaluation 19. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med. 2001; 344:1434-41. [PMID: 11346808] 20. O'Donnell S, Cranney A, Wells GA, Adachi JD, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database Syst Rev. 2006;3:CD005326. [PMID: 16856092] 21. Miller PD, Derman RJ. What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis? Osteoporos Int. 2010;21:1793802. [PMID: 20309524] 22. Cummings SR, San Martin J, McClung MR, et al; FREEDOM Trial. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med. 2009;361:756-65. [PMID: 19671655] 23. Gregg EW, Cauley JA, Seeley DG, Ensrud KE, Bauer DC. Physical activity and osteoporotic fracture risk in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1998;129:81-8. [PMID: 9669990] 24. Korpelainen R, Kein?nen-Kiukaanniemi S, Nieminen P, et al. Long-term outcomes of exercise: follow-up of a randomized trial in older women with osteopenia. Arch Intern Med. 2010; 170:1548-56. [PMID: 20876406] 25. Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients. A preplanned metaanalysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA. 1995;273: 1341-7. [PMID: 7715058] 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-5 (C) 2011 American College of Physicians Differential Diagnosis for Hip Fractures Pathologic fracture Pelvic fracture Osteoarthritis Osteonecrosis Rheumatoid arthritis affecting the hip Septic hip joint Dislocation Soft tissue injury Trochanteric bursitis Meralgia paresthetica (lateral femoral cutaneous nerve entrapment) Pathology referred from the lumbar spine (e.g., spinal stenosis, arthritis, disk disease) Paget disease (osteitis deformans) disease, various arthritides, periarticular disease, and certain neurologic disorders (see the Box). Radiographs can help distinguish hip fracture from other pathologic conditions. What characteristics of a fall are most predictive of hip fracture? Studies show that fall characteristics, such as fall direction and fall energy, are independent risk factors for fractures. A study of fall severity as a risk factor for hip fracture in ambulatory elderly persons showed that a fall to the side and higher fall energy were at least as important as BMD in determining hip fracture risk (28). A study of fall direction as a risk factor for hip fracture in frail elderly nursing home patients showed that a sideways fall was an independent risk factor for hip fracture (odds ratio for fall with hip fracture, 5.7 [CI, 1.7-18]; P 0.004 compared with patients who fell and did not sustain a fracture) (29). osteoporosis and increase the risk for hip fracture with a fall. What physical examination signs are helpful to diagnose hip fracture and to distinguish it from other causes of hip pain? Physical examination can confirm the diagnosis of hip fracture. The injured leg is often shortened, externally rotated, and abducted when the patient is in the supine position. What are the different types of hip fracture? Hip fractures are classified by the area of the upper femur affected and by whether displacement is present. The 3 types of hip fracture are intracapsular fractures at the level of the head and neck of the femur; intertrochanteric fractures between the neck of the femur and the lesser trochanter; and subtrochanteric fractures, which occur below the lesser trochanter (30). What other injuries commonly occur with hip fracture? In patients who present with a hip fracture after a fall, a search for other soft tissue injuries and other sites of fracture is warranted. Ask specifically whether concomitant head trauma occurred and examine the head for evidence of such. Some patients with hip fracture will have remained on the ground for a prolonged time, increasing their risk for deep venous thrombosis (DVT), skin ulceration, pneumonia, and rhabdomyolysis. What radiographs and other imaging studies are used? Radiographs are the cornerstone of diagnosis and are important in determining whether surgical repair is warranted. First, obtain plain anteroposterior pelvis and lateral radiographs. 26. Clemson L, Mackenzie L, Ballinger C, Close JC, Cumming RG. Environmental interventions to prevent falls in community-dwelling older people: a metaanalysis of randomized trials. J Aging Health. 2008;20:95471. [PMID: 18815408] 27. Gillespie WJ, Gillespie LD, Parker MJ. Hip protectors for preventing hip fractures in older people. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001255. [PMID: 20927724 ] 28. Greenspan SL, Myers ER, Maitland LA, Resnick NM, Hayes WC. Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA. 1994;271:12833. [PMID: 8264067] 29. Greenspan SL, Myers ER, Kiel DP, et al. Fall direction, bone mineral density, and function: risk factors for hip fracture in frail nursing home elderly. Am J Med. 1998;104:539-45. [PMID: 9674716] 30. The American Academy of Orthopaedic Surgeons. http:// orthoinfo.aaos.org/ topic.cfm?topic= A00392, accessed on March 6, 2011 What are the important elements of the history when hip fracture is suspected? The patient should be asked about the location and characteristics of pain, which is usually felt in the groin or buttock but can be referred to the knee. The circumstances of the fall and any history of trauma or height loss should be elicited. A general medical history should also be obtained, focusing on premorbid conditions and function (Table 2). Are physical examination findings of comorbid conditions (cardiac disease, cognitive impairment) predictive of hip fracture after a fall? Examination findings that suggest rheumatoid arthritis, hypogonadism, chronic glucocorticoid use, or kyphosis may be associated with (C) 2011 American College of Physicians ITC6-6 In the Clinic Annals of Internal Medicine 6 December 2011 If clinical suspicion remains high and plain radiographs are negative, obtain magnetic resonance imaging (MRI) to evaluate for occult fracture. A bone scan may be useful to diagnose fracture in patients who cannot undergo MRI, but may take up to 72 hours to register as positive. In studies of patients with suspicion of hip fracture but negative plain radiographs, MRI showed occult femoral fracture in 37% to 55% (31, 32). Table 2. History and Physical Examination Elements for Hip Fracture Category Element Notes History Trauma, particularly a fall from a standing position with impact directly on the hip Hip pain (groin or buttock) Inability to bear weight or pain with weight-bearing Circumstances surrounding fall To identify unstable medical illness before surgery and to identify potential areas for secondary prevention Rarely, pain may radiate or be referred to the knee or thigh Previous minimal trauma fracture or loss of height Risk factors for osteoporosis and fracture (e.g., sedentary lifestyle; excessive alcohol or tobacco use; weight loss since age 25; maternal history of hip fracture; use of psychoactive medications; use of seizure medications; hyperthyroidism; low dietary intake of calcium or vitamin D; and comorbid conditions, such as dementia and sensory deficits) Cardiovascular disease and other comorbid conditions Preoperative evaluation to determine if further testing or treatment is necessary before surgical repair, only in some circumstances (see text) Predicts morbidity and mortality after hip fracture Most patients do not tolerate anything more than a gentle attempt to roll the limb To evaluate for evidence of concomitant injury; particular consideration should be given to evaluation for head trauma To evaluate for interruption of the neurovascular blood supply at the level of the injury To evaluate particularly for evidence of arrhythmia, congestive heart failure, valvular disease, or uncontrolled hypertension that may need to be managed before surgery To identify unstable comorbid illnesses that may need preoperative evaluation and treatment or that may predict complications in recovery after fracture Delirium occurs in up to 60% of patients with acute hip fracture; the presence of cognitive impairment is a strong risk factor for development of delirium in the hospital and of worse recovery after hip fracture 31. Bogost GA, Lizerbram EK, Crues JV 3rd. MR imaging in evaluation of suspected hip fracture: frequency of unsuspected bone and soft-tissue injury. Radiology. 1995; 197:263-7. [PMID: 7568834] 32. Pandey R, McNally E, Ali A, Bulstrode C. The role of MRI in the diagnosis of occult hip fractures. Injury. 1998;29:61-3. [PMID: 9659484] Premorbid function Physical examination Observation of position and length of painful limb and gentle range-of-movement determination Musculoskeletal and neurologic survey Evaluation of distal motor, sensory, and vascular integrity of the affected limb Cardiac examination General physical examination Mental status testing 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-7 (C) 2011 American College of Physicians Diagnosis... History and physical examination distinguish hip fracture from other disorders that present as hip pain. Hip radiographs are important for diagnosis and for determining whether surgical repair is warranted. CLINICAL BOTTOM LINE Treatment and Management 33. Handoll HH, Parker MJ. Conservative versus operative treatment for hip fractures in adults. Cochrane Database Syst Rev. 2008: CD000337. [PMID: 18646065] 34. Parker MJ, Handoll HH. Pre-operative traction for fractures of the proximal femur. Cochrane Database Syst Rev. 2000: CD000168. [PMID: 10796311] 35. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture mortality. Relation to age, treatment, preoperative illness, time of surgery, and complications. Clin Orthop Relat Res. 1984:4556. [PMID: 6723159] 36. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg Am. 1995;77:1551-6. [PMID: 7593064] 37. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19:170-6. [PMID: 17309897] 38. Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291: 1738-43. [PMID: 15082701] 39. Sadowski C, Lubbeke A, Saudan M, et al. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg (Am) 2002; 84:37238 When should conservative therapy for be considered? Surgical repair is the cornerstone of therapy for hip fracture and has the best opportunity for functional recovery. Conservative therapy should be considered for patients who are too ill for surgery or anesthesia, patients who were bed- or wheelchair-bound before injury, or if modern surgical facilities are unavailable. A Cochrane review of 5 randomized trials found no differences in medical complications, mortality, or long-term pain in conservative vs. surgical therapy for hip fracture. However, surgery was more likely to result in fracture healing without deformity and a shorter hospital stay (33). Retrospective cohort studies generally show that long-term mortality is reduced when surgery is performed within 24 to 48 hours; however, data on morbidity conflict, and many of the studies do not give a reason for surgical delay (e.g., medical instability) (35-38). When should surgery be postponed? Surgery should be postponed if the patient has one or more unstable medical conditions, such as active heart failure, ongoing angina, or a serious infection. Any medical condition that causes hemodynamic instability should be corrected before fracture repair. How is the appropriate surgical approach determined? First, identify the location of the fracture and the severity of displacement, if any. Femoral neck fractures are repaired by either internal fixation with screws (if nondisplaced or minimally displaced in younger patients) or with prosthetic replacement (if displaced or in patients with concomitant poor bone quality, joint disease, or an excessive propensity to fall). Intertrochanteric fractures are repaired with sliding screws or other similar devices, depending on the bone quality and the surgeon's preference. Subtrochanteric fractures can be treated with an intramedullary nail or a screw-plate fixation. The results of 1 randomized trial supported use of an intramedullary nail rather than screw-plate fixation; patients treated with the former method had shorter surgical times, fewer blood transfusions, shorter hospital stays, and fewer implant failures and/or nonunions than patients treated with a screw plate (39). Is there a role for traction in conservative management of patients with hip fracture? No evidence indicates that skeletal or skin traction is beneficial for patients with hip fracture. In fact, traction may be associated with its own risks, such as increased patient discomfort, limited ability for bedpan transfer, increased immobility, and skin tears. A review presented by the Cochrane Musculoskeletal Injuries Group did not show any significant benefit from use of preoperative traction in patients with hip fracture (34). During what time frame should surgery be performed? Hip fracture should be surgically repaired as soon as the patient is medically stable, although the precise timing of surgery remains controversial. (C) 2011 American College of Physicians ITC6-8 In the Clinic Annals of Internal Medicine 6 December 2011 Note that displaced intracapsular hip fractures are very likely to disrupt the vascular supply to the femoral head, resulting in nonunion and osteonecrosis (up to 40%) if not treated with replacement arthroplasty (2, 40). Nondisplaced femoral neck and intertrochanteric fractures are less vulnerable to these complications and can often be treated adequately with internal fixation. Should preoperative cardiac risk be assessed in all patients who will have surgery for hip fracture? Orthopedic surgery is considered to have an "intermediate" cardiovascular risk; only patients with severe or unstable cardiac conditions are likely to benefit from revascularization before surgical hip repair. Thus, invasive and noninvasive cardiac testing are not indicated in hip fracture patients without comorbid cardiac conditions. The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery recommends perioperative testing and treatments only for the following specific cardiac conditions: o Unstable coronary syndromes, such as unstable angina, acute myocardial ischemia or infarction, and recent myocardial infarction o Decompensated heart failure o Significant atrial arrhythmias, such as symptomatic bradycardia, high-grade atrioventricular block, supraventricular arrhythmias with rapid ventricular rate at rest, and atrial fibrillation with rapid ventricular rate at rest o Ventricular arrhythmia o Severe valvular disease. Recommendations for perioperative medical therapies to reduce risk in patients with stable coronary artery disease have been updated in recent years. The ACC/ AHA recommends continuation of ?-blocker therapy in patients already receiving this therapy for angina, arrhythmia, and hypertension. They also recommend ?blockers to patients with identified coronary artery disease or high cardiac risk having intermediate-risk surgery (41, 42). The ACC/AHA Guidelines for perioperative testing and therapy offer a complete set of recommendations. Consultation with a cardiologist may also benefit a certain subset of patients (41, 43). What is the status of minimally invasive approaches for hip fracture repair? Minimally invasive surgical approaches for repair of intertrochanteric hip fractures result in lower rates of blood transfusions but no difference in mortality (44). What is the expected mortality of hip surgery? Surgical-specific mortality after hip fracture repair is 2%-3% in most U.S. hospitals; however, hip fracture confers a 5-fold increase for women and an 8-fold increase for men in all-cause mortality compared with age- and sex-matched controls in the first 3 months after fracture (45). What are the major postoperative complications of hip fracture? Major postoperative complications of hip surgery include infection, dislocation and failure of the prosthesis, delirium, DVT, skin breakdown, and bladder problems. What should be evaluated to assess these risks and other appropriate follow-up measures are shown in Table 3. Outpatient providers should be aware that late postoperative complications may occur months to years after repair and include osteonecrosis of the femoral head (after internal fixation), loosening of the prosthesis (after arthroplasty), and persistent pain (46, 47). 40 .Parker MJ. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. (Cochrane Review). In: The Cochrane Library. vol 4. Oxford: Update Software; 1999. 41. Fleisher LA, Beckman JA, Brown KA, et al; ACC/AHA TASK FORCE MEMBERS. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation. 2007;116:1971-96. [PMID: 17901356] 42. Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade.Circulation. 2009;120:e169-276. [PMID: 19884473] 43. Chopra V, Flanders SA, Froehlich JB, Lau WC, Eagle KA. Perioperative practice: time to throttle back. Ann Intern Med. 2010;152:4751. [PMID: 19949135] 44. Kuzyk PR, Guy P, Kreder HJ, Zdero R, McKee MD, Schemitsch EH. Minimally invasive hip fracture surgery: are outcomes better? J Orthop Trauma. 2009;23:447-53. [PMID: 19550233] 45. Haentjens P, Magaziner J, Col?n-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152:380-90. [PMID: 20231569] 46. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med. 1997;103:51S-63S; discussion 63S-64S. [PMID: 9302897] 47. Herrick C, StegerMay K, Sinacore DR, et al. Persistent pain in frail older adults after hip fracture repair. J Am Geriatr Soc. 2004;52:2062-8. [PMID: 15571543] 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-9 (C) 2011 American College of Physicians 48. Penrod JD, Boockvar KS, Litke A, et al. Physical therapy and mobility 2 and 6 months after hip fracture. J Am Geriatr Soc. 2004;52:111420. [PMID: 15209649] 49. Handoll HH, Sherrington C. Mobilisation strategies after hip fracture surgery in adults. Cochrane Database Syst Rev. 2007:CD001704. [PMID: 17253462] 50. Gillespie WJ, Walenkamp GH. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2010:CD000244. [PMID: 20238310 51. Morrison RS, Chassin MR, Siu AL. The medical consultant's role in caring for patients with hip fracture. Ann Intern Med. 1998;128:101020. [PMID: 9625664] 52. Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303-11. [PMID: 12791436] 53. Adunsky A, Levy R, Heim M, Mizrahi E, Arad M. Meperidine analgesia and delirium in aged hip fracture patients. Arch Gerontol Geriatr. 2002;35:253-9. [PMID: 14764364] 54. Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003;58:76-81. [PMID: 12560416] 55. Handoll HH, Farrar MJ, McBirnie J, et al. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2000:CD000305. [PMID: 10796339] 56. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:338S-400S. [PMID: 15383478] When should rehabilitation begin following surgery for hip fracture? Rehabilitation is a key component of treatment and should begin on the first postoperative day. Most patients should get out of bed on the first postoperative day, with progression to ambulation as soon as tolerated to prevent pressure ulcer formation, atelectasis, pneumonia, and muscle weakness. More intense physical therapy within the first 3 days after surgery has been shown to be associated with improved ambulation 2 months after surgery; however, the improvement is attenuated by 6 months after surgery compared with less intense physical therapy in the first 3 days after surgery (48). What the major components of pain management for hip fracture? Provide adequate analgesia to all patients with hip fracture, regardless of whether they have surgery. Analgesia increases patient comfort, facilitates rehabilitation, and decreases the risk for delirium. A large prospective study found that patients with higher postoperative pain scores had longer hospital stays and worsened short- and long-term functional recovery (52). Adequate doses of narcotics should be used to control pain, but meperidine should be avoided because it is strongly identified as a risk factor for delirium (53, 54). How common is thromboembolism following a hip fracture, and should it be prevented and treated? Rates of DVT up to 50% have been reported in patients with hip fracture not treated prophylactically. The rate of fatal pulmonary embolism was reported to be in the range of 1.4%- 7.5% within 3 months after hip fracture surgery (55, 56). Unless contraindicated, all patients should be treated with fondaparinux, low-dose unfractionated heparin, adjusted-dose vitamin K antagonist, or low-molecular-weight heparin to reduce the rate of thromboembolic complications. A randomized trial sponsored by the makers of fondaparinux comparing that drug with enoxaparin showed lower rates of (largely asymptomatic) DVT with fondaparinux, without any difference in bleeding or death. Fondaparinux is more expensive than enoxaparin, heparin, or vitamin K antagonists (57). Randomized trials that compared unfractionated or low-molecular-weight heparins with control showed a 59% reduction in DVT (51, 55, 58). What are the goals of rehabilitation and how are they best accomplished? The goals of rehabilitation are focused on regaining the previous level of ambulation and independence. The best strategies to improve mobility after hip fracture, however, have not been determined. Most studies of rehabilitation strategies are small and methodologically limited (49). What is the role of prophylactic antibiotics for patients who are having surgery for hip fracture? Prophylactic antibiotics should be administered to all patients, including those having surgery for closed fracture fixation, as they decrease the rates of deep wounds, superficial wounds, and urinary tract infections (50) The first dose of prophylactic antibiotics is given before surgery and continued for 24 hours after surgical repair. First- and secondgeneration cephalosporins have been used most often in trials. Meta-analyses have shown a 44% lower risk for infectious complications with antibiotic use vs. placebo and a 40% reduction of infection with multiple vs. single doses (51). For patients undergoing hip fracture surgery, the American College of Chest Physicians (ACCP) recommends the routine use of fon- (C) 2011 American College of Physicians ITC6-10 In the Clinic Annals of Internal Medicine 6 December 2011 Table 3. Elements of Postoperative Follow-up for Hip Fractures Category Issue How? How Often? Notes History Pain control Ask if pain is severe or if it is limiting therapy Bladder control Ask how much the patient has voided and whether dysuria is present Monitor for confusion or altered level of consciousness Physical examination Delirium Pressure ulcer Deep venous thrombosis History and physical examination Infectious complications Examine skin for evidence of breakdown Check for unilateral edema, erythema, warmth, and palpable venous cord Observe vital signs; examine lungs and wound; ask about symptoms of fever, cough, leg pain, or dysuria Ask about symptoms of chest pain, nausea, dyspnea, or diaphoresis; examine heart and lungs Ask about recent falls and the circumstances surrounding them; perform neurologic an musculoskeletal examinations, focus particularly on gait and balance Check hematocrit and electrolyte levels Ask patient and therapist and observe functional abilities Review medications, diet, alcohol and tobacco use, and exercise history; check serum TSH, 25-hydroxy vitamin D, calcium, phosphorus, and alkaline phosphate levels; consider checking serum and urine and protein electrophoresis or DEXA; oral bisphosphonate therapy should be held off during hospitalization until the patient is able to take it with 8 oz of water and remain upright for 30 minutes before eating, drinking, taking other medications, or reclining At least daily while an Pain medications may need adjustment; inpatient, then periodically new or increasing pain may warrant evaluation of stability of repair or for evidence of deep venous thrombosis or wound infection; evidence is insufficient to recommend one form of pain control over another (e.g., PCA pump vs. oral therapy), but most patients require narcotic therapy post-operatively, which can be tapered during recovery At least daily during acute Postoperative urine retention and infection hospitalization are common; the Foley catheter should be removed on postoperative day 1, then straight catheterization may be used if needed At least daily during A standardized screening tool, such as as acute hospitalization the Confusion Assessment Method, may be useful for diagnosis; altered mentation should prompt a search for the underlying cause Daily during acute hospitalization, then periodically until full mobility is achieved Daily during acute Venous Doppler ultrasonography may be hospitalization, then useful for evaluation if clinical periodically until full suspicion warrants it mobility is achieved Daily during acute hospitalization, then during outpatient follow-up as symptoms warrant Daily during acute hospitalization Delirium may be the sole presentation for acute MI or CHF in the elderly; electrocardiography may be helpful Assess efficacy and compliance with a falls-prevention program Cardiac complications Falls Periodically at each outpatient visit Laboratory data Nondrug therapy History, physical examination, and laboratory data Postoperative complications Rehabilitation Osteoporosis Daily during acute hospitalization until stable Daily while an inpatient, then periodically At the first outpatient Evaluate for diseases or conditions that follow-up appointment cause or exacerbate osteoporosis, and treat those that are amenable to therapy; initiate specific osteoporosis treatment based on individual patient characteristics then monitor for side effects, compliance, and efficacy; DEXA may be useful for monitoring therapy to enhance compliance, but its costeffectiveness is debated; because of ease of administration and reported ability to alleviate pain, calcitonin nasal spray may be initiated with calcium and vitamin D supplementation during hospitalization; evidence is insufficient that any osteoporosis therapies improve fracture healing rates CHF = congestive heart failure; DEXA = dual-energy x-ray absorptiometry; MI = myocardial infarction; TSH = thyroid-stimulating hormone. 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-11 (C) 2011 American College of Physicians daparinux, low-molecular-weight heparin, vitamin K antagonist (target international therapeutic range, 2.5; range, 2.0 to 3.0) or low-dose unfractionated heparin. They also recommend against the use of aspirin alone. Mechanical prophylaxis is recommended if anticoagulant prophylaxis is contraindicated because of a high risk for bleeding. The duration of prophylaxis is controversial. Studies show that the risk for venous thromboembolism begins soon after fracture. Prophylaxis should, therefore, begin before surgery if the procedure is likely to be delayed and should be restarted once postoperative hemostasis has been demonstrated. The ACCP recommends that patients undergoing hip fracture surgery be given extended prophylaxis for up to 28-35 days after surgery (59). What is the correct approach to secondary prevention in patients who have had a hip fracture? Outpatient follow-up includes evaluation of return of function, monitoring for late postoperative complications, and institution of secondary prevention measures. Analysis of data from the Framingham Heart Study showed that 2.5% of patients with hip fracture have a second hip fracture in the first year and 8.2% do so within 5 years of the first fracture (60). Secondary prevention measures include treatment for osteoporosis and fall prevention. A prospective, blinded, placebo RCT sponsored by industry showed that annual infusion of zoledronic acid started within 90 days after hip fracture and accompanied by daily calcium and vitamin D supplementation reduced both new fractures and mortality after hip fracture in the mean 1.9 years pf follow-up (61). 57. Eriksson BI, Bauer KA, Lassen MR, Turpie AG; Steering Committee of the Pentasaccharide in Hip-Fracture Surgery Study. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med. 2001;345:1298-304. [PMID: 11794148] 58. Gent M, Hirsh J, Ginsberg JS, et al. Low-molecularweight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation. 1996;93:804. [PMID: 8616946] 59. Geerts WH, Bergqvist D, Pineo GF, et al; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th ed). Chest. 2008;133:381S-453S. [PMID: 18574271] Treatment and Management... Surgical repair of hip fracture provides the best opportunity for functional recovery. Studies show that surgery performed within 24-48 hours reduces long-term mortality and should be done if the patient is medically stable. Perioperative cardiac testing and treatments are recommended only for specific cardiac conditions. Perioperative antibiotics reduce the risk for infectious complications. Postoperative anticoagulation is recommended to reduce the rates of DVT. Secondary prevention, including treatment for osteoporosis and efforts to reduce falls, is also indicated. CLINICAL BOTTOM LINE Patient Education What should patients be told about primary prevention of hip fracture? Patients should be educated about osteoporosis and its implications for risk for subsequent fractures if left untreated. They should also be educated about their future risk for falls and what they can do to prevent them. Poor vision, muscular weakness, certain medications, and many environmental factors are modifiable risk factors. What should patients be told about immediate care after a fall and the detection of hip fracture? Hip fracture and subsequent hospitalization are stressful to patients and their families. Knowing what to expect may alleviate some concern and guide modifications of the home (C) 2011 American College of Physicians ITC6-12 In the Clinic Annals of Internal Medicine 6 December 2011 or living arrangements to accommodate the increased needs of the patient. Approximately 50% of patients regain ambulatory status, and most gains in function are made in the first 6 months after fracture repair (2). Patients and their caregivers should be told that, barring any unstable medical conditions requiring preoperative treatment, most patients have the fracture repaired in the first day or two of hospitalization. They should also be told that rehabilitation is likely to begin on the first day after surgery, a 2-week stay in a rehabilitation facility is required before they can return home safely, and they will require assistance at home and further therapy for several months. What should patients with a hip fracture be told about the risk for recurrent fractures and how to prevent them? Analysis of data from the Framingham Heart Study showed that 2.5% of patients with hip fracture have a second hip fracture within the first year and 8.2% do so within 5 years of the first fracture (60). Commonly, patients with prior fractures are found to be receiving no specific therapy for osteoporosis at the time of their subsequent hip fracture, suggesting the opportunity to diagnose and treat osteoporosis before a hip fracture is missed. Therefore, it is important to educate patients about osteoporosis and its implications for risk for subsequent fractures if left untreated. Explain to the patient that he or she has "brittle bones" and requires therapy to reduce the chances of breaking other bones. Patient education can be instrumental in secondary prevention. Often, it is better if this information is delivered a few days after the fracture repair, when the patient is focusing on rehabilitation and recovery. Patient Education... Patients and their families should be educated on treatment for hip fractures and postoperative physical rehabilitation. They should also be educated on how to prevent future hip fractures. Interventions should include assessment of risk factors for falls and therapy for osteoporosis. CLINICAL BOTTOM LINE What measures do U.S. stakeholders use to evaluate the quality of care for patients with hip fracture? The Assessing Care of Vulnerable Elders, 3rd Set (ACOVE-3), quality indicators that are relevant to management of patients with hip fracture are those assessing perioperative care, falls, and osteoporosis management (62). What do professional organizations recommend regarding the care of patients with hip fracture? There are no guidelines from U.S. professional organizations; however, evidence-based guidelines for hip fracture management from Australia were published in 2008 and are consistent with the content of this manuscript (63). Practice Improvement 60. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women: the Framingham Study. Arch Intern Med. 2007;167:1971-6. [PMID: 17923597] 61. Lyles KW, Col?nEmeric CS, Magaziner JS, et al; HORIZON Recurrent Fracture Trial. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799809. [PMID: 17878149] 62. Wenger NS, Roth CP, Shekelle P; ACOVE Investigators. Introduction to the assessing care of vulnerable elders-3 quality indicator measurement set. J Am Geriatr Soc. 2007;55 Suppl 2:S247-52. [PMID: 17910544] 63. Mak JC, Cameron ID, March LM; National Health and Medical Research Council. Evidence-based guidelines for the management of hip fractures in older persons: an update. Med J Aust. 2010;192:37-41. [PMID: 20047547] 6 December 2011 Annals of Internal Medicine In the Clinic ITC6-13 (C) 2011 American College of Physicians Tool Kit Hip Fracture http://pier.acponline.org/physicians/diseases/d165 /d165.html PIER module on hip fracture from the American College of Physicians (ACP). PIER modules provide evidence-based, updated information on current diagnosis and treatment in an electronic format designed for rapid access at the point of care. Patient Information www.annals.org/intheclinic/toolkit-hip-fracture .xhtml Patient information that appears on the following page for duplication and distribution to patients. www.nlm.nih.gov/medlineplus/hipinjuriesand disorders.html www.nlm.nih.gov/medlineplus/tutorials /hipreplacement/htm/index.htm www.nlm.nih.gov/medlineplus/spanish/tutorials/ hipreplacementspanish/htm/index.htm Information on hip injuries and disorders from National Institutes of Health's MedlinePLUS, including an interactive tutorial on hip replacement in English and Spanish. www.niams.nih.gov/Health_Info/Bone/Osteoporosis/ Fracture/prevent_falls.asp Information on preventing falls and related fractures from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. www.cdc.gov/ncipc/factsheets/adulthipfx.htm Information on hip fracture among older adults from the Centers for Disease Control and Prevention. Clinical Guidelines www.annals.org/content/149/6/404.full Clinical practice guideline on the pharmacologic treatment of low bone density or osteoporosis to prevent fractures from the American College of Physicians. www.nof.org/professionals/clinical-guidelines Clinician's Guide to Prevention and Treatment of Osteoporosis, from the National Osteoporosis Foundation, released in 2008. Diagnostic Tests and Criteria www.uspreventiveservicestaskforce.org/uspstf10/ osteoporosis/osteors.htm Recommendations for screening for osteoporosis in postmenopausal women, from the U.S. Preventive Services Task Force, published in 2011. http://pier.acponline.org/physicians/diseases/d165 /tables/d165-t6.html Garden classification of femoral neck fractures. http://pier.acponline.org/physicians/diseases/d165/ tables/d165-t7.html Types of hip fracture repair. Quality of Care Guidelines www.qualitymeasures.ahrq.gov/ AHRQ quality indicator measure #19 for assessing the hip fracture mortality rate (the number of deaths per 100 discharges with principal diagnosis of hip fracture). (C) 2011 American College of Physicians ITC6-14 In the Clinic Annals of Internal Medicine In the Clinic 6 December 2011 In the Clinic PIER Module THINGS YOU SHOULD KNOW ABOUT HIP FRACTURE What is hip fracture? o A break near the top of the long bone running through the thigh (the femur), near the hip joint. o Pain after hip fracture may be felt in the groin or buttock, and possibly the thigh or knee. o Flexing or rotating the hip will cause discomfort. In the Clinic Annals of Internal Medicine What causes hip fracture? o The fracture usually occurs after a fall or some other trauma. o Most hip fractures occur in people older than 65 years, as aging bones become gradually weaker and more susceptible to breaks. o Osteoporosis is the main risk factor. o About 70% of hip fractures occur in women. How is it treated? o An x-ray or magnetic resonance imaging (MRI) is used to confirm diagnosis. o Surgery is usually required for repair. o The procedure is based on the location and extent of the fracture, patient age, and the surgeon's expertise. o In rare cases, treatment is nonsurgical. Nonsurgical treatment is usually reserved for patients who are too sick to have surgery or those who were unable to walk before the injury. o People who have one hip fracture are significantly more likely to have another. How can hip fracture be prevented? o It is important to start moving around soon after surgery to speed recovery and reduce complications. o It is usually necessary to use a walker, cane, or crutches and to participate in physical therapy for several months after surgery. o Muscle deterioration and weakness can lead to permanent loss of mobility. o Patients on bed rest are at increased risk for infections, bed sores, pneumonia, blood clots, and nutritional wasting. For More Information http://orthoinfo.aaos.org/topic.cfm?topic=A00305 Information on preventing broken hips from the American Academy of Orthopedic Surgeons. www.nlm.nih.gov/medlineplus/ency/article/007386.htm www.nlm.nih.gov/medlineplus/ency/patientinstructions/000168.htm Information on hip fracture surgeries and on postsurgical care from the National Institutes of Health's MedlinePLUS. http://nihseniorhealth.gov/osteoporosis/toc.html Patient information on osteoporosis from NIHSeniorHealt Patient Information What are common complications? o Keep bones strong by eating a nutritious diet with adequate amounts of calcium and vitamin D. o Be physically active to help maintain bone strength. o If you have osteoporosis, talk to your doctor about medicines that treat or prevent bone loss. o Prevent falls by remedying household hazards like slippery floors, poor lighting, and cluttered walkways. o Stairways should have handrails. o Review your medicines with your doctor and take only as directed. o Wear well-fitting, low-heeled shoes, and use walking aids correctly. CME Questions 1. An 87-year-old woman comes to the office for a routine evaluation. She reports that she has fallen once or twice a month for the past 4 months. The falls happen at various times of the day and occur immediately after standing up or after standing for some time. She does not experience dizziness, lightheadedness, vertigo, palpitations, chest pain or tightness, focal weakness, loss of consciousness, or injury at the time of the falls. The patient lives alone. Medical history includes hypertension and degenerative joint disease of both knees. Medications are acetaminophen and hydrochlorothiazide. On physical examination, temperature is normal, blood pressure is 135/85 mm Hg without postural change, pulse rate is 72/min, and respiration rate is 16/min. Visual acuity with glasses is 20/40 on the right and 20/60 on the left. Cardiopulmonary examination is normal. There is bony enlargement of both knees without warmth or effusion. On balance and gait screening with the "get-upand-go" test, the patient must use her arms to rise from the chair. Neurologic examination, including cerebellar testing and a Romberg test, is normal. The patient's score on the Mini-Mental State Examination is 26/30 (normal >=24/30). Results of a complete blood count and blood chemistry studies are normal. Which of the following should be included as part of her management at this time? confused and was found on the floor of her room at about 3 am. Her assessment found no sign of injury, and vital signs were normal. The patient was released from the hospital without further incident 2 days later. The patient's medical history is significant for osteoporosis and hypothyroidism. A geriatric assessment within the past year revealed a Mini-Mental State Examination score of 29/30 (normal >=24/30) and full activity of daily living capability. Current medications are hydrocodone, levothyroxine, diphenhydramine, aspirin, and fondaparinux. The patient's records show that meperidine was ordered on a routine schedule, and an additional order was to be given for breakthrough pain. Which of the following system-level interventions will be most helpful in preventing future falls in other patients in similar circumstances? jugular venous distention. The lungs are clear. There are no murmurs or gallops. Serum creatinine is 1.5 mg/dL (132.6 umol/L). An electrocardiogram shows normal sinus rhythm with Q waves in leads II, III, and aVF; nonspecific ST-T wave changes; and left ventricular hypertrophy. A chest radiograph is normal. Which of the following is the most appropriate preoperative cardiac testing? A. Coronary angiography B. Dobutamine stress echocardiography C. Exercise (treadmill) thallium imaging D. Resting two-dimensional echocardiography E. No additional testing is indicated 4. An 82-year-old woman is evaluated at the hospital after tripping and falling. She fractured her right hip and needs urgent hip replacement. She reports no angina, chest discomfort, syncope, or presyncope. She has had no signs or symptoms of heart failure. Before the fall, she was active and walked daily. On physical examination, temperature is normal, blood pressure is 164/82 mm Hg, and pulse is 96/min. BMI is 26. Point of maximal impulse is undisplaced. There is a normal S1 and a single S2. There is a grade 3/6 systolic ejection murmur on examination heard at the right upper sternal border that radiates to the left carotid artery. Carotid pulses are delayed. Transthoracic echocardiogram demonstrates severe aortic stenosis and normal left ventricular size and function. Pulmonary pressures are normal. Which of the following is the best perioperative management option? A. Begin collecting adverse drug event prevalence data B. Implement a fall-risk prediction tool for newly admitted patients C. Reengineer the hospital room architecture to decrease fall risk D. Standardize protocols for management of opiate medications 3. An 85-year-old man presents with a left hip fracture. He has been very healthy and is able to walk 4 or more blocks. He has a 3-year history of occasional chest pain that occurs less than once each month and develops only after walking too quickly. There has been no change in the severity or frequency of the chest pain and no dyspnea. Medical history is significant for a myocardial infarction 4 years ago, type 2 diabetes mellitus, and hypertension. Current medications are metoprolol, fosinopril, atorvastatin, insulin glargine, metformin, and aspirin. Blood pressure is 140/80 mm Hg, pulse rate is 60/min. BMI is 30. There is no A. Begin risedronate B. Measure serum 25-hydroxyvitamin D level C. Prescribe hip protectors D. Schedule 24-hour electrocardiographic monitoring 2. An 83-year-old woman who is recuperating from hip replacement surgery was evaluated on the orthopedic floor of a hospital when she became A. Aortic balloon valvuloplasty B. Aortic valve replacement C. Intra-aortic balloon placement D. Intravenous afterload reduction (nitroprusside) E. Proceed directly to hip replacement Questions are largely from the ACP's Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/ to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program. (C) 2011 American College of Physicians ITC6-16 In the Clinic Annals of Internal Medicine 6 December 2011 I I II II I I IFMIIE I I I Iwlm SCAN HEALTH PLAN Appeals and Grievances Process Currently In Force In Type Force Y PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY PUBLISHED POLICY ID Title Revision 2 Last Revised 09/10/2009 GA-0016 Web Site Grievance Submission GA-0011 Expedited Grievance Process GA-0018 Correspondence Processing GA-0003 Grievance Resolution Policy GA-0002 Expedited Appeals Process Administrative Law Judge (ALJ) Hearing 3 2 16 16 Y Y Y Y 12/09/2009 02/05/2010 02/12/2010 08/13/2010 GA-0020 3 Y Y Y 11/24/2010 01/06/2012 04/09/2010 GA-0024 Part D Expedited Grievance Process 2 GA-0019 California Department of Social Services Fair Hearings 2 GA-0001 Standard Appeals Process GA-0030 Medi-Cal Grievance and Appeals Resolution Process 17 New Y Y 03/30/2010 04/09/2010 Part D Standard Grievance GA-0023 Resolution Process (pka: Part D Grievance Resolution Process) 2 Y 01/06/2012 I I II II I I IFMIIE I I I Iwlm Duals Demonstration Program Chris Wing Chief Executive Officer Bill Roth Randy Stone Tim Schwab, M.D. Douglas Jaques Chief Operating Chief Financial Chief Medical and Sr. Vice President, Officer Ofltcer Vision Officer General Counsel Sherry Stanislaw - . Elizabeth Russell Becky Learner Sr. Vice President, President, Sr. Vice President, Marketing in . Arizona Compliance i cu Miner No- Sr. Vice President, 3 . National Sales Pmied Ma?a??r Duals Operations at Acme UAH) I 1 Member I Communi County Agencies Advisory Committee HBCS Partners I I II II I I IFMIIE I I I Iwlm Proposed key staff members chart Key Staff Members Tim Schwab, MD Eve Gelb Jodi Cohn Lisa Roth Kimberley Johnson Moon Leung Roy Swackhamer Karen Sugano Lena Perelman Denise Likar Nathan Norbryhn Ray Chan, MD Title Chief Medical Officer VP Health Care Services Administration Research Director Geriatric Practice Innovation Director of GHM, PALs and Independent Living Power Manager of PALs and Independent Living Power VP Health Care Informatics Chief Information Officer VP of Network Management Director of Community Outreach Director of Independence and Home Director of Health Care Services Medical Director Relevant Skills and Leadership Ability Clinical and organizational leadership, knowledge of dual eligible public policies and regulations, quality assurance Leadership, planning, case management expertise Gerontological expertise and community relationships Project oversight, Case management and dual eligible expertise Project management, Case management and dual eligible expertise Research and evaluation skills, statistical skills Knowledge of IT hardware, software, leadership and planning skills Knowledge of strategies for engaging contracted health care providers Knowledge of and linkages with community based organizations Knowledge of and linkages with community based organizations Knowledge of strategies for engaging contracted health care providers Knowledge of provider networks, established relationships with providers and knowledge of integrated care models I I II II I I IFMIIE I I I Iwlm CURRICULUM VITAE Timothy Carl Schwab, M.D., F.A.C.P., M.H.A. Chief Medical Officer - SCAN Health Plan Professional Address: Long Professional Telephone: Email Address: Education: Fort SCAN Health Plan 3800 Kilroy Airport Way, Suite 100 Beach, CA 90801 (562) 989-8316 tschwab@scanhealthplan.com B.S.- Colorado State University Collins, Colorado 1966-1970 M.D. - University of Colorado School of Medicine Denver, Colorado 1970-1974 M.H.A. - University of LaVerne LaVerne, California 1988-1991 Internship: St. Mary's Medical Center Long Beach, California 1974-1975 Internal Medicine St. Mary's Medical Center Long Beach, California 1975-1977 Chief Resident Internal Medicine St. Mary's Medical Center Long Beach, California American Board of Internal Medicine, 1977 Harriman Jones Medical Clinic Beach, California ployee 1978-1979 1979-1988 an of Board 1985-1987 1978-1996 t Clinical Professor Residency: 1977-1978 Certification: Practice: Long Em Partner Chairm Affiliation: Assistan CURRICULUM VITAE Timothy Carl Schwab, M.D., F.A.C.P., M.H.A. Departm School Employment: Medical St. February Medical January Chi 1998-Present Chief SCAN Long ent of Medicine of Medicine, UCLA June 1988 - February 1990 Director Mary's Medical Center Physicians of Greater Long Beach, an IPA 1990-1992 Director 1993-1998 ef Medical Officer Medical/Informatics Officer Health Plan Beach, California SCAN Health Plan Responsibilities: Supervise Medical Director Department and all Quality oversight activities Supervise Pharmacy Department Supervise HealthCare Informatics Department (includes data warehouse, BI activities, HEDIS management, research and quality improvement activities (1999 - 2011) Social HMO Site Director (1990-end of demo in 2007) ESRD SNP demo site director (2005- end of demo in 2010) Public and Government Affairs (1999- 2009) CA relationship for duals contract Memberships: Am Am Am Am California California Gerontological Long National Committees: American College of Physician Executives American College of Physicians - American Society of Internal Medicine erican Geriatric Society erican Health Insurance Plans erican Medical Association erican Medical Directors Association Association of Health Plans - Medical Directors Medical Association Society of America Beach Medical Association Los Angeles County Medical Association Academies of Practice American College of Physicians - American Society of Internal Medicine 3rd Party Relations, Coding, and Payment Subcommittees (2001-2008) Managed Care Subcommittee (1998-2000) American Health Insurance Plans 2 CURRICULUM VITAE Timothy Carl Schwab, M.D., F.A.C.P., M.H.A. Comm Leadership Managed Delegate ittee on Quality Care American Society of Aging Council of the Managed Care and Aging Network (1997-1998) American Society of Internal Medicine Care Committee (1996-1998) Committee on Quality and Utilization (1994-1996) 1988-1996 Conventions Committee on Health Care Financing (1991-1993) ARV Assisted Living Advisory Committee (1998-2000) California Chapters ACP Services of Directors (2005- present) California Lutheran Homes of Directors (1997-2000) pensation Committee (1998) California Society of Internal Medicine Committee ACP-CSIM (1998-1999) (1995-1996) reasurer (1994) (1988-1993) bership Committee (1987-1990) Member Relations Committee (1987-1988) Front Porch Corporation of Directors (1999-2004, 2006-2011) Business Development & Assessment Committee Chairman (2003-2004) Finance Committee (1999-2003) Audit Committee (2006-2011, chair 2008-2011) Harriman Jones Medical Clinic Director Executive Physical Program (1982-1988) Director Immediate Care Clinic (1982-1988) Committee (1981-1988) Records Committee (1985-1986) Management Committee (1982-1986) (Chairman 1984-1986) Chairman Department of Medicine (1982-1984) Long Beach Society of Internal Medicine President (1987-1988) Prudential Plus of Orange County 3 Medical Board Board Com Merger President Secretary/T Trustee Mem Board Medical Finance Medical CURRICULUM VITAE Timothy Carl Schwab, M.D., F.A.C.P., M.H.A. Quality Assurance Committee (1988-1990) St. Mary's Medical Center Medicine Committee (1981-1984) 1982-1984 (Chairman 1983) Pharmacy & Therapeutics (1978-1982) (Chairman 1980-1982) Review (1979-1982) St. Mary's Medical Education Department Competency Committee (1980-1991) Selection Committee (1980-1991) Geriatrics Utilization Clinical Intern-Resident Community Activities: California Olmstead Committee (appointed by Secretary of HHS) Member 2005 - present Mem California 1115 Waiver Committee (appointed by secretary of HHS) ber 2008 - present California Long Term Care Integration Technical Advisory Committee Member 2010 - present (support of CMMI dual integration grant) Physical Health California State University, Long Beach Therapy Advisory Committee (1994-2005) Center for Health Care Innovation Advisory Committee (1998-2006) Care Administration Dept Advisory Committee (2006 - present) City Of Long Beach Blue Ribbon Commission on Health in Long Beach (2001-2002) Los Angeles County Aging & Disabled Services Community Roundtable (2001-2002) OnLok PACE Regulatory Integration Project (2004-2005) Developer Appointed SCAN Health Plan and Facilitator, Geriatric Advisory Board (2005-present) White House Conference on Aging as Delegate (2005) 4 I I II II I I IFMIIE I I I Iwlm SCAN Health Plan Operational Plan Quarter Timeline 01/20/12 - 03/31/12 On 02/24/12 On 03/01/12 Q1 2012 By 03/31/12 By 03/31/12 By 03/31/12 By 03/31/12 By 04/02/12 04/01/12 - 04/30/12 04/01/12 - 04/30/12 Q2 2012 04/01/12 - 04/15/12 04/01/12 - 04/30/12 04/01/12 - 05/15/12 04/10/12 - 04/20/12 By 04/15/12 By 04/16/12 Start 05/01/12 05/01/12 - 05/31/12 05/01/12 -05/31/12 05/01/12 - 12/31/12 Activity Outreach to key partners and stakeholders Submit Request for Solutions to DHCS Begin Network Analysis Conduct Business Impact Assessment Develop detailed operational work plans for all supporting functions and begin deployment of plans Explore initial facility/site expansion Conduct IT infrastructure review Submit NOIA to CMS Create separate Duals business unit and structure Recruit and hire Duals business unit leadership Finalize staffing plans for new CA Duals business unit and shared services departments within SCAN Confirm all workflow and IT business requirements Review business processes and protocols and update documentation as needed Develop staff recruitment strategy and staffing rampup plan Identify and hire external experts if needed Submit Part D Formulary for all SCAN product lines Recruit staff and begin training Complete necessary facility build-out Install or expand IT and/or telephonic systems Deploy provider contracting activities Quarter Timeline By 05/07/12 By 05/15/12 Start 06/01/12 By 06/04/12 By 06/08/12 On 07/30/12 08/01/12 - 09/20/12 08/01/12 - 09/30/12 By 09/20/12 10/01/12 - 12/31/12 Start 10/1/12 Activity Submit MTMP to CMS Respond to DHCS via the Demonstration Proposal state comment period Develop beneficiary outreach and educational materials and plan informing documents Complete CMS Bid/benefit design and submission Submit Supplemental Formulary Files, Free First Fill file, Partial Gap Coverage File to CMS Receive final CMS decision regarding state demonstration proposals Participate in Site Readiness Reviews with CMS and State of California Refine beneficiary on-boarding processes Execute contract with CMS and State of California Conduct support staff training Begin distribution of plan materials Start accepting enrollments for a 01/01/13 effective date Continue to execute staffing plan based on projected monthly enrollments Continue beneficiary on-boarding activities Conduct health risk assessments Assign case managers Execute care plans Contracting continues and address any network gaps Develop and implement mechanisms to gather beneficiary and stakeholder input on year 1 Q4 2012 Start 10/15/12 Throughout 2013 Throughout 2013 Start 01/01/13 2013 Start 01/01/13 Start 01/01/13 Throughout 2013 Throughout 2013 Quarter Timeline Activity performance Throughout 2013 Throughout 2013 2014 Throughout 2014 Throughout 2014 2015 Throughout 2015 Throughout 2015 Develop and implement mechanisms to gather staff input on year 1 performance Conduct Stakeholder outreach Develop co-location arrangements for behavorial health and substance abuse treatments Continue with local stakeholder outreach activities Continue to develop co-location arrangements for behavorial health and substance abuse treatments Continue with local stakeholder outreach activities