Medical Home Subgroup – Needs Determination

October 19, 2011 – Meeting Notes

DRAFT

Attendance: Marsha Fretwell, MD (co-lead); Teresa Piezzo (co-lead); Betsey Tilson, MD; Elise Bolda

Purpose of the Subgroup –1) Develop a process for determiningneeds of recipients across the continuum of care2) Develop tool(s) toaid physicians/providers to: assess needs of patients, track progress of patients, and link to eligibility. This tool may replace/enhance the FL2 Level of Care Determination

Initial thoughts on possible Key Elements for consideration:

  • Continuity of Care
  • Medical and nursing coverage. Engage team of primary care providers
  • Decrease inappropriate hospitalizations and save hospital days -1) Create financial incentives for physicians, ‘craving rational systems’, 2) support trusting relationships between primary care providers and patients
  • Move off medical model to functional model; Make maximizing patient’s functional health the overarching goal of new system of care
  • Anticipation of Need of Resources – Tool that is flexible, functionally based, can be used at intervals over time with scoring mechanism that can be also related to outcome measures
  • What is the patient’s goal or preferences
  • Importance of linking LTC world

Tools discussed/briefly reviewed and shared with the group:

  • Tool for Standard Domains for Functional Assessment and Outcomeused by Elderhaus (drawn from MDS) and has been a very effective tool in their PACE program. Refer to Attachment.
  • Maine –Medical Eligibility Determination (MED) used to assess independent and assess eligibilityfor 20 Medicaid and state-funded programs. It also functions as a way to let recipients know their resources. It is a ‘spigot’ for adjusting eligibility/changing the allocation of resources
  • Michigan - Medicaid Nursing Facility LOC Determination include eligibility criteria for long term care services
  • Asthma Assessment Tool used by CC of Wake/Johnston Counties (reference attachment)
  • Florida – Hospital to SNF Transfer Form (Pilot Test Form)

Articles Shared:

  • Risk Adjustment of Medicare Capitation Payments Using CMS-HCC Model
  • Med-Pac June 2011 Coordinating Care for dual-eligible beneficiaries

Discussed a conceptual ‘Functional’ matrix (see attachment) with the possibility of attaching allocation of resources to functional needs across the entire population, currently NC uses the FL-2 Level of Care Determination Tool for nursing homes other tools for other programs.

Need a clinically relevant screening tool for physician use that can help “score” a patient as to needs. This “score” could correspond to a box in the functional matrix which could define elements needed/covered for care. This could be used for determination of eligibility and help providers know of available resources. The tool could also flag high risk for more in-depth assessment. The tool could be used by providers in multiple settings to aid in consistent assessments and communication.

Lessons may be available in the steps & stages approach used for asthma and obesity.

Reminders to the group = PACE will be explored by another group

Possible requests to other groups:

  • Definition of Medical Home
  • Palliative Care – what are key screening questions?
  • Behavioral Health – – what are key screening questions - Poly-pharmacy: Medication Encephalapathy

Next Steps:

  • Review Asthma/Obesity tools of CCofWake/Johnston Co information to be sent by Betsey Tilson
  • Determine domains
  • Meet 11/7/2011 9-11am Conference Room #4
  • Next Meeting – Review Priority Criteria with Subgroup/ Deliverables/Parking Lot

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