Long Term Care Integration

As is true nationwide, San Diego is facing a daunting challenge: responding to the growing need for improved access to coordinated chronic care supports within systems built to deliver acute care. Last calendar year in San Diego, 95,000 aged and disabled individuals eligible for Medi-Cal incurred an estimated $1.7 billion in Medi-Cal and Medicare costs. As the population grows, costs will continue to increase, even without inflation. Quality of care will be comprised unless there is a transformation in how care is delivered. There is both a need and an opportunity for systems change. The Long Term Care Integration Project (LTCIP) is poised and ready to jumpstart needed activity for such a change in San Diego thanks, in part, to the support and participation of the County Medical Society and local physicians. As the project reaches a critical turning point, now is the time for more physicians to get involved.

The Long Term Care Integration Project (LTCIP) has been a multi-year collaboration between the County’s Health and Human Services Agency and a large group of community stakeholders that includes physicians, consumers, caregivers and other health and social service providers. The vision is a single health and social service system of care management for elderly and disabled persons, with “no wrong door” entry into the system, a plan of care shared by all providers, and funding that is pooled to allow for flexibility and creativity in providing “seamless,” consumer-centered care. This vision is being realized through three distinct and complementary strategies:

• Healthy San Diego Plus (HSD+) is a voluntary, fully integrated service delivery model that would combine a Medi-Cal and Medicare capitated rate to qualified managed care health plans, provide the flexibility to purchase services that meet individual needs and preferences rather than a prescribed list of benefits, and increase resource delivery and communication. County staff and community stakeholders are working with local and state officials to establish regulatory authority to implement a fully integrated acute and long term care integration program consistent with the local either through the legislative process or State interpretation of existing authority.
• The Physician Strategy is planning for a managed fee-for-service approach with similar goals to HSD+, but with the choice to remain in the current fee-for-service system. The goal is to engage and support providers to improve chronic care outcomes through better resource information, communication, consumer education and empowerment, and a “virtual” care team.
• The Aging & Disability Resource Center (ADRC) Strategy supports the two service delivery models described above, as it facilitates access to health and social service resources through enhanced communication, web-based technology and service referral tools via the Network of Care website (www.sandiego.networkorcare.org) and Call Center at Aging & Independence Services. Third year of grant will focus on making continued enhancements to the website, strengthening the ADRC partnership with the disability community and engaging in outreach and education activities to make the broader community more aware of the ADRC and available resources.

Each strategy can stand alone, but together, all three strategies offer the most comprehensive way of creatively meeting the needs and preferences of San Diego’s elderly and disabled residents, their caregivers and providers.

During the Physician Strategy planning phase, both physicians and community providers identified lack of coordination of care across settings as a major obstacle to optimum outcomes for those individuals most in need of help. While many system problems were identified, an implementation proposal has been developed in the form of a community health education and training initiative that addresses this barrier with a practical eye to realistic influences and resources. Physicians involved in the planning stage reviewed a draft of the implementation which was revised and improved with their feedback. The proposal has been submitted to a foundation for grant funding.

The basic idea is to encourage a community infrastructure of support for consumers and their primary care providers around chronic care management. This will help physicians to not be overwhelmed by the growing need of people for social services that compliment their medical care. Primary care physicians will support office staff, home health nurses, social workers, pharmacists, caregivers, social service providers, and others involved in their patient’s care to participate in the initiative and take joint ownership for the patient’s outcomes as a community team. The pay off will come from the development of a new knowledge base and philosophy leading to:

• a more complete understanding of chronic care management and the need to plan and follow-up after office activities;
• ability to use the Network of Care web tool for referral resources, patient education, personal health record-keeping, etc.;
• collaborative team relationships between physician offices, ancillary providers and local neighborhood social service providers;
• improved coordination of after office services with feedback to the physician/staff on successful implementation of the patient care plan by the community team; and improved patient outcomes.

To be successful, the Long Term Care Integration Project recognizes the value of physicians as critical members and key informants to this initiative. All physicians are encouraged to participate at any level possible. Please call Evalyn Greb at 858-495-5428 or Sara Barnett at 858-692-3252 for more informaton.