title
Consider adopting a resolution accepting the State Department of Health Care Services approval of Solano County’s application for the Whole Person Care project; Authorize Health and Social Services to pursue a sole source contract with Solano Coalition for Better Health, a qualified community based organization; and Delegate authority to the County Administrator to sign a grant agreement and related documents, accept funds totaling up to $4,667,010 over five years, and effectuate all matters necessary to the timely execution of the grant agreement
body
Published Notice Required? Yes ____ No _X _
Public Hearing Required? Yes ____ No _X _
DEPARTMENTAL RECOMMENDATION:
The Department of Health and Social Services (H&SS) recommends that the Board of Supervisors adopt a resolution accepting the Department of Health Care Services (DHCS) approval of Solano County’s Whole Person Care (WPC) project application; Authorize Health and Social Services (H&SS) to pursue a sole source contract with Solano Coalition for Better Health (SCBH)--a qualified community based organization; and Delegate authority to the County Administrator to sign a grant agreement and related documents, accept funds totaling up to $4,667,010 over five years, and effectuate all matters necessary to the timely execution of the grant agreement;
SUMMARY:
Medi-Cal 2020, California’s five year Section 1115 Medicaid Waiver, will guide the State through the next five years in an effort to transform the way Medi-Cal provides services to its more than 13 million members, and improve quality of care, access, and efficiency. Among the programs covered under the new Waiver is the Whole Person Care Program. This is the county’s investment in the changing healthcare system in California. Whole Person Care focuses on changing a fragmented and expensive health care system to a more comprehensive health care delivery model looking at the whole person from a more integrated care management approach.
Multiple Divisions in Health and Social Services collaborated to apply for the Whole Person Care Grant on July 5, 2016. The Department was informally notified on September 28, 2016 that it would shortly receive a grant agreement and would need to expedite the approval and acceptance by the Board of Supervisors to begin program activities and expedite receipt of the grant funds. The project will feature a collaboration between H&SS and a sole source contractor, SCBH, who currently operates a similar program, Transitional Care Program (TCP), which combines complex care management with Housing First approaches. This program also engages community partners including the hospital systems, Partnership Health Plan and the CAP Solano JPA.
Pursuant to the terms of the grant, the Department will be reimbursed based on demonstrated expenditures and achievement of measurable outcomes. Through consultation with DHCS, identified outcomes have been designed to be attainable and achievable. Some of the identified outcomes include monthly care coordination meetings being held, number of days of inpatient hospitalization, hospital readmission rates, and Primary Care Physician enrollment and engagement. At the appropriate time, request for approval of an Appropriations Transfer Request will be made.
FINANCIAL IMPACT:
Funding for the WPC Pilot Project is contingent upon meeting specific program deliverables. After DHCS determines the amount to be reimbursed based on a semi-annual review of deliverables met, the County is required to process an Intergovernmental transfer (IGT) to draw down federal funds. H&SS identified unmatched Mental Health Services Act (MHSA) expenditures to support the IGT based on the interpretation of guidance from DHCS. H&SS estimates an annual IGT transfer of $466,701 to draw down approximately fifty percent federal matching funds. This will fund the annual total project cost of $933,402 for a period of five years, assuming all program deliverables are satisfactorily met.
H&SS anticipates the first IGT will not begin until late June 2017. H&SS will assess available appropriations at Third Quarter and will submit an Appropriation Transfer Request if necessary. The grant budget as submitted does not include County General Fund. However, the County may bear 100 percent of the share of costs associated with any unmet program deliverables. H&SS staff have worked carefully to define deliverables in such a way as to maximize the achievement of such deliverables and minimize any financial risk to the County.
From a fiscal perspective, the program offers the opportunity for less hospital visits for high end patients due to more aggressive care management allowing more patients to be seen in primary/clinic care environment. Funds received through the WPC Pilot will be directed to contract services. H&SS will receive revenue through direct client services.
DISCUSSION:
California’s 1115 Waiver Renewal, called Medi-Cal 2020, was approved by the Centers for Medicare and Medicaid Services (CMS) on Dec. 30, 2015. Among the programs covered under the new Waiver is the WPC. The WPC Pilot represents a new direction in Health Care by focusing on high medical utilizers with a dedicated multi-disciplinary team targeting individuals with chronic high cost medical conditions and comorbid behavioral health problems that may contribute to frequent hospitalizations, poor self-care, and unnecessary deterioration of medical status. Medi-Cal 2020 provides up to $1.5 billion statewide to match local public funds and Solano is in the first wave of counties that applied and have been approved to receive such funding. Through the wide dissemination of this approach in relation to certain high risk segments of the Medi-Cal population, the Federal government and the State of California, hope to achieve the Triple Aim of Health care: better quality services at lower costs with high patient satisfaction.
The WPC pilots are a 5-year program authorized under California’s Medi-Cal 2020 waiver to test locally-based initiatives that will coordinate physical health, behavioral health, and social services for vulnerable Medi-Cal beneficiaries who are high cost users of multiple health care systems and continue to have poor outcomes. Through collaborative leadership and systematic coordination among public and private entities, WPC pilots will identify target populations, share data between systems, coordinate care in real time, and evaluate individual and population health progress. The pilot funds for WPC are specifically designated for the following purposes: 1) building infrastructure to integrate services among local entities that serve the target population; 2) providing services not otherwise covered or directly reimbursed by Medi-Cal to improve care for the target population, such as housing components; and 3) implementing strategies to improve integration, reduce unnecessary utilization of health care services, and improve health outcomes.
On July 5, 2016, H&SS submitted an application for the WPC Pilot that targets services to the highest 250 medical utilizers in the County during the past 12-24 months with complex, comorbid conditions such as substance use disorders, mental illness and other disabilities. During the life of the grant, which effectively extends from January, 2017 through 2021 due to the delayed application cycle, rather than a five full years, 250 Medi-Cal enrolled individuals will be enrolled in a Health Home (if not already), receive high intensity outreach and engagement services, housing supports, multi-disciplinary treatment, and active, daily or weekly care management of the kind that has been found to be effective with such individuals. ‘Project 25’ in San Diego and other projects like it have demonstrated that intensive intervention that addresses behavioral conditions along with high cost medical conditions are more successful at producing positive care outcomes and reducing continued high cost medical utilization. H&SS would be responsible for administrative oversight of program delivery, funding, and outcomes, as well as direct provision of primary care, behavioral health and substance use services.
In Solano County, SCBH operates a variety of health and health promotion programs, among which is the TCP. This program serves homeless individuals presenting to several Emergency Departments in Solano and coordinates housing, care, and linkage to resources, while offering continued follow-up to ensure individuals who otherwise would default for their care to Emergency Rooms, instead receive preventive services in an outpatient setting. Evaluation of care outcomes and cost benefit analysis demonstrates that this approach has resulted in improved health care outcomes and significant cost avoidance. Because CMS and the State Department of Health Care Services have an extremely aggressive timeline, and because SCBH offers a unique program blending housing approaches with care management and outreach approaches, H&SS believes that a sole source contract is fully justified. SCBH has unique and critical capabilities in demonstrating results with a like model in their TCP, as well as being the only entity that brings together the County Medi-Cal Managed Care Plan, multiple hospital systems, and Health and Social Services for an aligned and strategic health system. It is not recommended that the grant be opened for RFP, as Year 1 of the Pilot project is currently underway. To engage in an RFP process would be costly due to lost grant funds for deliverables in gathering benchmark data and hiring staff for year one. If approval is granted to pursue a sole source contract with SCBH, the contract will be brought back to the Board of Supervisors at a future date for final approval.
Along with other initiatives in Medi-Cal 2020, the WPC approach is considered the most promising direction for health care authorities to ensure quality care for high risk, high cost individuals. This new focus on ‘Super-utilizers’ of medical and behavioral health care with highly integrated team-based services is considered a blue-print for improved care outcomes and containment of escalating health care costs. It represents a focus on vertical integration, or focused integration on select high risk populations
Through intensive outreach, engagement, and complex care management, individuals who typically arrive in emergent states at Emergency Departments will be helped to enter treatment, find housing, and receive support and training in how to engage in appropriate self-care for their given medical condition. They will receive priority entry into existing Medi-Cal resources pursuant to MOU’s among the participating partners (listed below under Agency Participation), including the County’s Medical Services Clinics (FQHC’s). Through SBCH each individual will have assigned a specialized nursing professional whose sole job it is to ensure that all involved treatment providers are coordinating optimally, informed in real time of significant status changes of the patient, and who will track progress on each of the participants and communicate these through a multi-disciplinary care platform.
Since statistical research demonstrated that this population is riddled with substance abuse problems, but do not generally access substance abuse treatment, existing county substance abuse personnel will be specially dedicated to this project to ensure streamlined entry and follow-up in the County’s Substance Use Disorder system, while participants with mental illness will be prioritized for entry into formal treatment in the County’s Mental Health System.
Many of the participants will suffer from housing instability or be homeless; therefore, a major focus of the program is to develop capacity for transitional housing while participants are able to become enrolled in SSI and obtain more permanent housing elsewhere, or return to work and pay rent.
What makes this program innovative is its combination of assertive street outreach, follow-up and monitoring, with assertive complex care management that builds a physical and virtual team of caring providers around each participant. It mirrors a national health care best practice trend to take a vertical approach to integration, meaning that integration occurs strategically around individuals at the very highest risk, and that these individuals, or ‘super-utilizers’ of services receive prioritized service entry, coordination, and resources in order to improve their care outcomes and reduce costs significantly.
On average, individuals in this program may have hospital utilization patterns of upwards of $180,000 per year. Through participation, it is expected that costs to both our local hospital systems, law enforcement, and social service systems will be reduced. The current SCBH TCP results demonstrate decreases in medical costs associated with Emergency Department and inpatient admissions, making the return on investment (ROI) roughly 4 dollars for every 1 dollar invested in the current program. These savings are calculated without taking into account collateral use such as the jails, law enforcement, or other community resources typically enlisted by the target population, resulting in an even higher true ROI. As annual reports are required to DHCS, Health & Social Services will provide annual reporting to the Board and County Administration for the duration of the pilot period.
ALTERNATIVES:
The Board may choose not to approve this resolution. This is not recommended because adults with mental health and substance use issues with high cost chronic health conditions would not be able to benefit from this approach to improving their care and health outcomes, and the State may not request further proposals. Additionally, while Medi-Cal funding is available for the direct services to this population (primary care, behavioral health, substance use treatment), this funding allows for non-covered services such as Complex Care Coordination and housing support services.
OTHER AGENCY INVOLVEMENT:
Partnership Health Plan of California; Northbay Hospital; Sutter Hospital; Kaiser Permanente; Sheriff’s Department; Solano Coalition for Better Health; H&SS Administration, Behavioral Health, and Public Health, Medical Services; CAP Solano JPA.
CAO RECOMMENDATION:
APPROVE DEPARTMENTAL RECOMMENDATION