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North Carolina’s Proposal to the Centers for Medicare & Medicaid Services (CMS) for the “State Demonstration to Integrate Care for Dual Eligible Individuals”

I. North Carolina’s Approach to Integrating Care for the Dual Eligible Population

The North Carolina Medicaid Agency (Division of Medical Assistance), with support from the Innovation Center, is committed to plan and implement a health care delivery system that integrates health care and supportive services for the dual eligible population. Creating a strategic framework and implementation timeline over the twelve month planning phase will enable us make the necessary changes in Medicaid policy and reimbursement so incentives are aligned in support of a patient-centered model of care. In addition, it will provide us with the time needed to engage the stakeholders in this process so that the ultimate model will be successful. Historically, states have not focused on managing the dually eligible beneficiaries due to the lack of shared savings opportunities. Currently, the North Carolina Community Care Program is participating in the 646 Medicare Health Care Quality Improvement demonstration, where the initial focus is managing the care of duals in 26 counties. We believe our 20 year history in creating state-wide medical homes (Carolina ACCESS), our 12 year history of implementing population management strategies in the Medicaid population (Community Care of North Carolina) coupled with our more recent experience working with duals in the 646 Quality Demonstration provides us with the infrastructure, experience and insight to develop and implement a better system of health care for the dually eligible population in our State.

North Carolina will provide a replicable model that can be applied in both urban and rural settings since we are prepared to implement a new delivery system across all 100 counties in our state. Twenty percent of our 9.2 million residents are below 100% of the Federal Poverty Level; 1.1 million of our residents are aged 65 or older and 14% of those over 65 are poor (Kaiser Family State health Facts 2008-2009).

a) Target Population – North Carolina has 284,160 duals: 82.6% (234,589) of those duals are listed as living at home; 10.6% (30,164) reside in nursing homes; 6.7% (19,118) reside in adult care homes. Based on a recent Kaiser Issue Paper entitled “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Services Use and Spending” (July 2010), we expect that three in five (60%) of our duals will have multiple chronic conditions, one of our five (20%) percent will have more than one mental/cognitive condition, and almost 2 in 5 duals (40%) have both a physical and mental disease or condition. Half of the duals age 80 or older will have both a physical and mental /cognitive conditions. In analyzing its dual data, North Carolina has identified among dual beneficiaries the following prevalence of selected physical and mental conditions:

Medical Conditions Percent of Duals with ConditionHypertension 73%Three or more chronic diseases 54%Diabetes 39%Mental Health Condition 32%Ischemic Vascular Disease 24%COPD 19%Asthma 13%Chronic Kidney Disease 11%

North Carolina’s Proposal to Integrate Care for Dual Eligible Individuals

The top five hospital admissions for North Carolina Duals were: psychoses, syncope and collapse, renal failure, heart failure, and chronic obstructive pulmonary disease. We also found that 40% of duals will have at least one emergency room visit during a year and 26% will have at least one hospitalization.

b) Approach to Integrating Care for the Dual Eligible Population – North Carolina’s approach for integrating care for dual eligibles is to build on the statewide infrastructure (Community Care of North Carolina) that North Carolina has built to improve the delivery of health care for vulnerable populations. The goal is to partner with long-term care providers, home and community-based providers, area agencies on aging, and other stakeholders to design, in concert with dual-eligibles and their families a health care delivery system for duals that can provide the right care at the right time and that will help us achieve the “triple aims” – improving the health of the dual eligible population; improving the quality, access and reliability of care; and reducing or containing the costs of care.

North Carolina’s substantial experience in both developing and operating chronic care improvement programs for Aged, Blind and Disabled Medicaid recipients and for dual eligible beneficiaries in 26 North Carolina counties under the Medicare Health Care Quality Demonstration (646) has convinced us that no one approach will work. The complexity of the dual population combined with the variety of living arrangements requires far more targeted approaches to creating an integrated program that can achieve lasting improvements in care and care outcomes. North Carolina will build its integration strategy around the duals living arrangement; home, nursing home, and adult care home. While there will be common approaches, particularly in the identification and management of chronic illnesses, which will cross living arrangements, each setting will have unique challenges that will require special strategies, initiatives and partnerships.

Dual Eligibles Living at Home – North Carolina’s Community Care program has implemented a Chronic Care Program to manage their enrolled aged, blind and disabled population, including the duals, both, as part of the 646 demonstration and as enrollees in Community Care. Designed to build upon Community Care’s established foundation, the Chronic Care Program emphasizes an enhanced care management processes with strong ties to the medical homes and built new connections with community-based long-term care providers and hospitals. Community Care partnered with those providers to improve how care is organized and delivered and to ensure accountability for managing individuals with chronic conditions. For example, many of the networks developed relationships with the Aging, Disability and Resource Centers, with local organizations representing the elderly and disabled communities, and with home and community-based providers.

The Chronic Care Program is designed to be “patient-centric”, addressing the patient’s physical, social and behavioral health needs. The networks have reorganized the delivery of care in ways that enhance appropriate access, increase service delivery options, improve efficiencies in the identification, assessment and care planning processes, support transitions in care, reduce the rate of hospitalizations and re-admissions, and reduce the unnecessary inefficiencies and expenses inherent in the current system. Gleaning best practices from this initiative, the following core elements, at a minimum, would be included in the design and implementation of an integrated delivery system for the dual eligible population living at home in North Carolina:

Screenings and assessments Patient-centered plans of care Team based care with the Primary Care Provider (PCP) of the patient’s medical home leading the multi-

disciplinary team Behavioral health integration


Population management activities, including disease and care management, pharmacy management, transitional care, acute and preventive care, care coordination, etc.

State-wide medical home infrastructure and comprehensive provider network Strong home and community based options Patient and family caregiver involvement, including self-management Robust data-sharing and communication system Consumer protection and advocacy Aligned financial incentives for high quality cost effective care

Dual Eligibles Living in Nursing Homes – Division of Medical Assistance (DMA)/Community Care will work with stakeholders to build on the Chronic Care Program in planning the design of the enhanced integrated program. In partnership with the nursing homes and long-term care providers, DMA/ Community Care will, in addition to integrating Chronic Care Program services into the nursing home setting, develop a targeted nursing home integration plan that will include:1) Improving Transitions in Care2) Managing Prescription Drugs

Because of the historical disincentives that have come with a split Medicaid and Medicare system for duals, nursing homes have almost no incentive to limit the hospitalization of Medicaid nursing home residents. As part of its integration effort, North Carolina will work with its nursing homes to provide the support, through use of nurse practitioners tied to Community Care networks and medical homes, to supplement nursing home staff in providing the early identification and preventable care that could reduce the need for hospitalizations. We also expect to explore an incentive payment to Nursing Homes for reducing avoidable hospital and ED admissions.

In regards to improving the management of prescription drugs for duals in nursing homes, the establishment of the Medicare Part D program transferred payment of prescription drugs to the Medicare program and created an abundance of new players, Part D plans and Medicare Advantage Plans, who have no responsibility for any aspect of dual-eligible care other than their prescription drugs. The Long-Term Care Pharmacies supply the Part D with drugs for duals and also review drug use. Because the nursing home piece is only a small portion of a Part D plan’s business, there are limited incentives and means to influence drug utilization in nursing facilities, where typically the facility determines the drugs to be used. Community Care participated in a nursing home pharmacy management initiative that was described in the December 2004 American Journal of Geriatric Pharmacotherapy, D. Christiensen et al entitled “A Pharmacy Management Intervention for Optimizing Drug Therapy for Nursing Home Patients”. The study findings presented the impact of a single retrospective drug regimen review targeting nursing home patients. Considering only personnel costs and fees paid to consultant pharmacists, the program produced a cost-minimization ration of 12:1 and the interventions resulted in a higher quality drug regimen. In a new model targeting the duals, DMA/Community Care will work in concert with the nursing facilities to replicate and expand upon this pharmacy management model.

Dual Eligibles Living in Adult Care and Assisted Living Homes – In collaboration with the adult care and assisted living providers and the Community Care Networks and Medical Homes, North Carolina will develop an integrated program that will improve the management of patient care through better assessment, communication and outreach. Based on interviews with adult care home staff to identify needs and concerns related to patient care, the following initiative is now being piloted with 27 adult care homes:

o Intervention – Dually-eligible patients are identified based on their medical conditions(s) and health status and prioritized for care management interventions. Within the adult care home a registry of


patients targeted for interventions is maintained. Once patients are identified for intervention, care managers perform the following services:

Review of medical and pharmacy data to identify areas of concern Assessment and identification of gaps in care Improve access to primary care physicians Coordinate care with physicians and health care team Meet regularly with care home staff regarding patient monitoring and follow-up Conduct medication reconciliation

o Goals – The overall goal is to improve health outcomes, improve the coordination of care and contain costs. Specific objectives include:

Decrease % of duals with diabetes who have an A1C > 9% Decrease % of duals with hypertension who have a blood pressure > 140/90 Decrease unnecessary hospitalizations and ED admissions

Unlike nursing homes, where there are nurses and other clinical staff on site, adult care homes are, by definition, residential settings where no clinical support is available on-site. This reality makes the support provided by the Community Care Networks and participating medical homes (in concert with the Adult Care Home staff) absolutely essential to achieving improvements in dual care and outcomes in this setting.

II. North Carolina’s Capacity and Infrastructure

North Carolina has invested in the development of a state-wide population management system – Community Care of North Carolina. This program serves the state’s most vulnerable and high cost populations. Through access to primary care medical homes, vigilant care management and provider collaboration, Medicaid recipients and low-income uninsured residents have access to more comprehensive, high-quality care that is less costly to administer. Through Community Care, North Carolina has developed an infrastructure that improves care for Medicaid recipients and provides a vehicle for improving care for all patients. It is a private-public collaborative effort through which the State has partnered with community physicians, hospitals, health department and other community organizations to build regional networks to improve the quality, efficiency and cost-effectiveness of care for Medicaid recipients. It is the Community Care infrastructure that serves as the platform for a Medicare Health Care Quality Demonstration (646) and Multi-Payer Advanced Primary Care Demonstration with the Centers for Medicare & Medicaid Services (CMS) and would enable North Carolina to develop and implement an integrated delivery system aimed at the dually eligible population.

Currently the state-wide Community Care program serves over 1 million Medicaid enrollees, over 50,000 uninsured, and over 83,000 dual-eligibles, through fourteen networks, and approximately 1,300 medical homes and over 4,000 primary care providers. The networks have the clinical and administrative leadership and community-based care managers (>500); pharmacists (>19); psychiatrists (>14); system administrators and privacy officers (>14) and other staff to support the population management activities. The networks have also built active partnerships with most components of the local health care delivery system, including hospitals, health departments, specialists, community-based organizations and other community providers. The population management tools used to achieve positive results in quality, cost and utilization, include the following: providing a patient-centered medical home; implementing evidence-based best practice programs; providing targeted care and disease management; coordinating care delivery with an emphasis on improving transitions; improving patient self-management skills; implementing pharmacy management strategies; helping practices improve management of chronic illness care; and providing a structure within which community providers can work to improve enrollee care and outcomes.


This infrastructure brings engaged physician leaders throughout the state together to identify program priorities, adopt and implement quality and utilization performance metrics and spread best practices to community providers and agencies. The development of a new system to manage the dual eligible will need a collaborative partnership among all stakeholders and the local Community Care network will have the leadership, ability and history to develop and implement an integrated delivery system that addresses the barriers and disincentives inherent in the current system.

Other providers serving the dual eligible population include 1,019 nursing facilities, 79 Hospice agencies and 1,200 Adult Care Homes. There are 3 Special Needs Plans offered in North Carolina serving patients with chronic or disabling conditions, dual eligibles and institutionalized individuals. In addition, North Carolina implemented the Program for All-Inclusive Care for the Elderly (PACE) in February 2008. The PACE program goal is to manage all the health and medical needs of this frail population to keep them out of the hospital or a nursing facility for as long as possible. Once patients are enrolled, the PACE Program provides all the medical care, social services and personal care services required by the individual. At present two organizations operate PACE Programs in North Carolina: Elderhaus, Inc of Wilmington and Piedmont Health Services, Inc. of Carrboro. Plans are underway for 2 additional PACE providers to begin operations within the next several months. Ten additional organizations have indicated they intend to submit PACE applications by the end of the year. North Carolina will work closely to align all efforts of the project with the PACE program throughout the state to learn best practices and maximize available resources to keep individuals safely in the community.

The North Carolina Medicaid Program also operates several 1915(C) Home and Community-Based Waiver Programs that include adults: The NC Supports Waiver and NC Comprehensive Waiver provides adult day health, day supports, home and

community supports and in home services and training for individuals w/autism, Developmental Disability, Mental Retardation.

CAP/DA (Community Alternatives Program/Disabled Adults) provides adult day health, case management, institutional respite, care advisor (CHOICE option only), assistive technology, home modifications and mobility aids, meal preparation and delivery, non-institutional respite, participant goods and services, personal assistant (CHOICE option only), personal care aide, PERS, training and education, transition, waiver supplies for individuals 65 years of age or older.

CAP Choice provides adult day health, respite institutional, in-home aide, personal assistant, care advisor, FMS, consumer-directed goods and services, home modifications and mobility aids, preparation and deliver of meals, respite (in-home), telephone alert, waiver supplies for aged individuals 65 years or older and for the disabled between 18 and 64 years of age.

The Piedmont Behavioral Health Waiver allows selective contracting to provide mental health, developmental disability, and substance abuse services to all age groups in a 5 county area.

The North Carolina Medicaid agency and the Division of Aging both serve under the N.C. State Department of Health and Human Services. The organizational structure allows our agencies to work together closely and to align initiatives. The Division of Aging has Area Agencies on Aging (AAA) that are established through the Older Americans Act that serve to facilitate and support the development of programs to address the needs of older adults in a defined geographic region and support investment in their talents and interests. In North Carolina, AAAs are located within regional Councils of Government. These AAAs have functions in five basic areas: (1) advocacy; (2) planning; (3) program and resource development; (4) information brokerage; and (5) funds administration and quality assurance. These agencies will be important in the development and implementation process and already have stakeholder processes in place.


"Community Resource Connections for Aging and Disabilities" (CRC) is North Carolina’s implementation of the federal Aging and Disability Resource Center initiative. This program is also housed in the N.C. Department of Health and Human Service. The main goal of this initiative is "community" collaboration. Through this collaboration, agencies and organizations within the community work together to provide information about, assistance with, and access to services for individuals who are aging or have a disability. There are 8 existing centers across the state with 4 additional sites in development. A CRC is one of the primary vehicles to modernize long-term care systems, particularly by supporting individuals of all disabilities and incomes to make informed, cost-effective choices regarding the services they may need.

In the summer of 2009, 8 counties were chosen to pilot an initiative with the Division of Aging and Adult Services called “Community Care Connections”. The goal of this pilot was to bring all the stakeholders together to increase communication between the community partners and create replicable approaches of community collaboration involving Departments of Social Services, Area Agencies on Aging and Community Care Networks and to identify and enrich community resources targeting the aged, blind and disabled population.

North Carolina has a demonstrated history of collaboration with private-public partnerships and agencies that will be able to develop, implement and support an integrated delivery system for the duals.

III. North Carolina’s Current Analytic Capacity

The North Carolina Community Care‘s “Informatics Center” is an electronic data exchange infrastructure maintained in connection with health care quality initiatives for the State of North Carolina sponsored by the Department of Health and Human Services Division of Medical Assistance, Office of Rural Health and Community Care, and the United States Department of Health and Human Services Centers for Medicare & Medicaid Services. Currently, the Informatics Center contains health care claims data provided by Medicaid, as well as health information about program participants obtained directly from health care providers and care managers and/ or the primary care medical record. New data sources have been integrated into the Informatics Center in 2010 to include: Medicare claims and Surescripts pharmacy data for dual eligibles, LabCorp (laboratory results), and real-time hospital admission/discharge/transfer data from 48 large NC hospitals.

Community Care has recently begun to receive Medicare part A and B claims data from CMS for duals participating in the 646 demonstration. This data will be used in the Informatics Center data warehouse to identify the 646 duals, track performance measures and quality improvement outcomes.

Information is accessed by the Community Care networks to identify patients in need of care coordination; to facilitate disease management, population management, and pharmacy management initiatives; to enable communication of key health information across settings of care; to monitor cost and utilization outcomes; and to monitor quality of care and provide performance feedback at the patient, practice, and network level. The Informatics Center houses the following programs:

Care Management Information System (CMIS) CMIS is a web-based portal accessible to all networks, allowing care managers to maintain a health record and single care plan that stays with the patient as he or she moves across provider settings. Community Care networks are able to utilize CMIS to manage enrollment, eligibility and care management services for HealthNet projects across the state, which are regional collaboratives for the care of the uninsured. Thus CMIS enables a continuity of care record for patients as they migrate “in and out” of Medicaid, Health Choice (North Carolina’s SCHIP program) and un-insurance. CMIS provides a standardized framework for care manager workflow management and documentation, incorporating tools for patient screenings and assessment, goal setting, and


health coaching. In addition, CMIS has report-designing capability for monitoring caseloads and activities of the care management workforce.

Pharmacy HomeThe Pharmacy Home Project was created to support Community Care pharmacy management initiatives, and address the need for aggregating information on drug use and translating it to the network pharmacist, case manager and primary care provider in a manner best suiting their care delivery needs. The system provides a patient level profile and medication history for point-of-care activities, as well as a population-based reports system to identify patients that may benefit from pharmaceutical care delivery via pharmacists, case managers and PCPs in the medical home. The Pharmacy Home drug use information database is used prospectively for multiple purposes: for identification of care gaps and problem alerts; targeting of at-risk patients; development of the pharmaceutical care plan; and proactive intervention to assist providers and patients with therapeutic substitution required by state Medicaid policy. Retrospective uses of the Pharmacy Home database are equally important, to enable efficient and timely analyses needed for continuous quality improvement and program evaluation. Medicare Part D pharmacies claims are currently not available to us. Community Care has contracted with Surescripts to receive prescription fill history for the 646 duals. We could expand our contract with Surescripts to include any additional duals covered in this demonstration.

Quality Measurement and Feedback Chart Review SystemChart audit, quality measurement and performance feedback has always been an integral component of Community Care’s clinical quality improvement initiatives. Community Care clinical leaders have remained committed to the monitoring of quality at the individual practice level, to engage providers in the quality improvement process and to monitor progress at the practice, county, network, and statewide level. As the Community Care program expanded to serve a larger population with multiple complex co-morbidities, a broader array of quality measures was adopted, using evidence-based care guidelines for diabetes, asthma, hypertension, cardiovascular disease, and heart failure. Community Care now conducts over 26,000 medical record reviews in over 1250 primary care practices statewide on an annual basis. To manage the expanding scope of the chart review process, we moved from a paper chart abstraction tool to a fully electronic, streamlined system in 2009. Medicaid claims data is used to generate a random sample of eligible patients, and to pre-populate audit tool elements according to an individual’s identified chronic conditions. Practices and CCNC networks have immediate access to chart review results through a secure web-based report site, with patient-level information as well as practice, county, network, and statewide results with national comparative benchmarks.

• Informatics Center (IC) Reports Site The IC Reports Site was created to allow the efficient and secure distribution of reports through a secured web-based report access and management application, with report access permissions determined by the appropriate scope of access of individual users. Network-level administrators authorize their own employees and providers by customizing their scope of access by practice or region. A report built at the statewide level can be readily distributed according to the permission tree structure, such that only the appropriate patient information is visible to each end user. Various functions are served by our analytics and reporting capacity:

Population Needs Assessment: Identification of demographic, cost, utilization, and disease prevalence patterns by service area. The Community Care Chronic Care patient database contains over 80 data elements and is updated quarterly to reflect the current aged, blind, and disabled enrolled population. Network leaders can readily obtain information about the demographic characteristics, prevalence of chronic medical and mental health conditions, spending by category of service, and rates of hospital, ED, and other service use within their county-level service areas. This aids in program planning and resource


allocation; identification of outlier patterns (such as unusually high rates of personal care services); and tracking of local utilization patterns over time.

Risk Stratification, Identification of High-Opportunity Patients, Patient-level Information. The size and complexity of the Medicaid population, in terms of physical health, mental health, and socioeconomic needs, necessitates intelligent mechanisms for identifying patients most appropriate for care management interventions. The use of historical claims data to screen patients for care management intervention can greatly improve the efficiency of the care team. We are able to flag patients who meet specified criteria for further screening by a care manager, according to patterns of service use over the prior 12 months (such as multiple ED and inpatient visits, multiple medications, lack of PCP contact, target medical conditions, and high cost). We flag approximately 17% of the population for screening, and approximately 5% as highest priority for screening. In addition, we flag patient who meet criteria for mental health case management based on mental health service use, in order to best leverage external case management resources and coordinate care. Similar reports are generated for specific initiatives or pilot programs (for example: identification of patients with newly diagnosed asthma, heart failure, and diabetes; identification of patients receiving controlled substance prescriptions from multiple sources; identification of patients with poor adherence to their blood pressure medications for a telephonic health coaching intervention).

Monitoring of ED and Inpatient Visits. A number of detailed utilization reports are generated automatically from the IC data warehouse, updating with every claims payment cycle. These can be easily navigated by local managers and clinicians who may not be highly technically savvy. As an example, the user can readily access a listing of ED visits by their enrolled population. The report can be parameterized by hospital, PCP, or patient or visit characteristics; and can tally visit counts by patient or practice. A similar report is available for inpatient hospitalizations. These reports are very flexible for answering a variety of questions (e.g.: Are patients from my clinic having a high number of non-emergent ED visits during regular office hours? How many heart failure discharges were readmitted within 30 days, and did they bounce back to the same facility or to a different location). In addition to claims data, all networks receive real time ED data from hospitals in the community.

Tracking of Care Quality Indicators. In addition to the quality measures tracked in the annual chart review process, we are able to track a number of quality measures using claims data alone, with quarterly updates. Measures can be aggregated to the practice, county, network, or statewide level. Results can be viewed in spreadsheet format for easy comparative view across practices, or as a comprehensive practice-level, county-level, network-level, or program-level report with trend information. Reports include measures related to diabetes, asthma, heart failure, cardiovascular disease, pediatric well visits and dental care, and adult breast, cervical, and colorectal cancer screening. Program Evaluation and Tracking of Key Performance Indicators. The IC Reports Site also enables program performance tracking for monthly reporting to the state Medicaid agency and state legislature. Tracking of key metrics provides stakeholders with assurance that efforts are aligned toward the overarching goals of cost savings and quality improvement, and that all networks are held accountable for the overall performance of the program. Key indicators include both process measures (such as percent of targeted hospitalized patients receiving medication reconciliation) and outcome measures (such as hospitalization, ED, and readmission rates). The Medicare claims data for 646 duals is also available to us and will be used to track improvement in performance measures and quality outcomes.


• Provider Portal The Informatics Center Provider Portal was released in August of 2010. This portal was built with the treating provider in mind, offering elements of CMIS, Pharmacy Home, and the Reports Site, tailored to the target user. Through a secure web portal, treating providers in the primary care medical home, hospital, emergency room, or mental health system can access a Medicaid patient health record which includes patient information, care team contact information, visit history, pharmacy claims history, and clinical care alerts. Importantly, the use of Medicaid claims data provides key information typically unavailable within the provider chart or electronic health record. For example, providers are able to see encounter information (hospitalizations, ED visits, primary care and specialist visits, laboratory and imaging) that occurred outside of their local clinic or health system. Contact information for the patient’s care manager, pharmacy, mental health therapy provider, durable medical equipment supplier, home health or personal care service provider is readily available. Providers can discern whether prior prescriptions were ever filled, and what medications have been prescribed for the patient by others. Built-in clinical alerts appear if the claims history indicates patient may be overdue for recommended care (e.g. diabetes eye exam, mammography).

The Provider Portal also contains key resources for assisting providers in the management of Medicaid patients, such as a library of low-literacy patient education materials, and practice tools for risk assessment and disease management.

North Carolina Medicaid has access to a portion of the Medicare claims for its dual Medicaid and Medicare population. The claims that are available have a distinct claim type but are co-mingled and have the same format as the Medicaid claims in both the Medicaid Management Information System (MMIS) and Medicaid data warehouse. The available claims include most Medicare Part B professional claims which seem to be “crossed over” to the (MMIS) by the Medicare processing contractors. These claims are processed and integrated with other claim types. They are processed weekly and presented with other claims data for use in reports. In contrast, only a portion of the outpatient facility, inpatient facility and skilled nursing home claim are processed by the MMIS. Claims for services for which Medicaid would not make an additional payment to the billing provider are not currently being processed by the MMIS. In addition, North Carolina Medicaid does not receive Medicare Part D pharmacy data nor are these claims currently available to any state Medicaid program. Without all the Medicare claims it is not possible to accurately produce the same type of reports of quality measures for duals that are created for the Medicaid-only population. The lack of some Medicare claims also creates gaps in the visit history displayed in the Community Care provider portal and the pharmacy home application.

Complete Medicare Part A and Part B claims are available to a small selection of Medicaid users. North Carolina’s Program Integrity unit has access to a combined Medicare and Medicaid data warehouse operated by AdvanceMed, the North Carolina Medi-Medi contractor. The Medi-Medi federal contract is designed to assist with fraud and abuse detection only and the AdvanceMed warehouse is not available to staff outside of the Program Integrity unit. And while it has complete Part A and Part B data, AdvanceMed does not receive Part D pharmacy data. Ensuring the availability of Medicare data will be critical to the success of an integrated model.

Non-claims Data Sources for the Dually Eligible Population are used to help fill the gaps in needed information to maximize population management activities and these sources include:

Surescripts – is used to acquire prescription fill history data for dual Medicare/Medicare clients who are part of the 646 Waiver project. The feeds return a twelve month prescription history and come from multiple pharmacies or prescription benefit plans. This is particularly helpful for practices that do not yet have an e-prescribing tool that is certified with Surescripts for fill history transactions.


Ensuring access to Medicare Part D data will be important to integrate and manage the care of the dual population.

Lab Data – the IC receives historical and monthly lab results for Medicaid recipients, including dual eligibles, whose lab claims were billed to LabCorp. This historical data represented labs for 230,000 Medicaid recipients and LabCorp provides an ongoing monthly data feed. Results for 125 selected tests are displayed as part of the patient record in the Provider Portal.

Hospital Admission, Discharge and Transfer (ADT) Data – contracting with Thompson-Reuters to supply twice daily feeds of inpatient, outpatient, and emergency room admissions. Transactions include the chief admission complaint and identify the attending physician. Transactions are immediately reported to Community Care care managers in the Case Management Information System (CMIS) and are consolidated into reports housed in the Community Care report site. Thus far, twenty-eight NC Hospitals have signed on to participate in this data sharing relationship, to improve care coordination for Medicaid recipients post-discharge. Once the rollout is complete, Community Care will receive ADT data from 48 North Carolina hospitals, representing over 60% of ED and Inpatient visits for the NC Medicaid and dual eligible population.

IV. Summary of Stakeholder Environment

North Carolina is committed to soliciting stakeholder input throughout the program design process. Stakeholders include consumers, providers, advocacy groups, county departments of social services, community-based organizations, and other state agencies that work with the duals. The North Carolina Medicaid Program works closely with several agencies that will also be identified as key stakeholders for this demonstration: AARP, N.C. Division of Aging (DOA), N.C. Department of Insurance (DOI), and Aging and Disability Resource Center (ADRC).

The North Carolina Medicaid program works closely with all local departments of social services (DSS’s) and develops and implements the Medicaid eligibility policy for all 100 counties which also includes the Medicaid portion of the duals. Medicaid Program Representatives (MPRs) are located regionally throughout the state to work directly with the DSS staff to provide statewide caseworker training on new eligibility policies and other targeted training on identified problem areas. Caseworkers work directly with clients to educate and enroll them into all eligible social programs and have great insight regarding issues and approaches. The MPRs also monitor county compliance to assure clients receive timely and accurate determination of benefits.

The North Carolina Department of Insurance (DOI) State Health Insurance Program (SHIP) works closely with our seniors regarding health care issues. DMA has worked closely with DOI regarding new health care initiatives such as implementation of Medicare Part D and the Medicaid Long Term Care Five Year Lookback federal regulation. We continue to partner with DOI regarding ongoing issues that involve the duals and would partner with them in this new initiative. In addition, our Community Care Program works closely with our area aging groups to sponsor health education classes. We are also working with AARP regarding focus group studies of duals and their caregivers.

Emerging Innovations in Best Practice Currently North Carolina is participating in the 646 Medicare Health Care Quality Demonstration. North Carolina and Indiana are the only 2 states that are participating in this demonstration. This first-hand experience in working with both Medicare and Medicaid programs and consumers, has given us a solid foundation to build on in developing a proposal to integrate care for the duals.


Implementation of the 646 demonstration began on January 1, 2010 in 8 Community Care networks. Since the first part of this demonstration targets the dual population exclusively, we have new and emerging models of best practice that can be leveraged and used in developing an integrated dual plan:

Home visits to patients by care managers (CMs): Many of the CMs perform home visits after a patient is discharged from the hospital to promote self-management skills such as assisting patients in making needed follow-up medical appointments as well as performing medication reconciliation. It is during these visits that CMs may discover drug interactions or duplications, particularly after a hospital discharge. Consultation with the primary care provider, hospital and network pharmacist takes place when problem areas are identified.

Networks also provide medication reconciliation through network pharmacists. Much of this activity takes place in providers’ offices and in hospitals.

A large 646 primary care practice is embedding a nurse practitioner into the practice that will perform home visits to all patients discharged from the hospital within 3 to 5 days. The practice also has two CMs embedded in the practice.

Care Management in Adult Care Homes: One large multi-site Federally Qualified Health Center (FQHC) has developed integrated care management services to help manage the 646 duals and Chronic Care Population. The initiative focuses on dually eligible patients in area Adult and Family Care Homes. The program is designed to facilitate improved care management of these patients through better assessment, communication and outreach. The intervention is based on a “treatment in place” model. o Semi-structured interviews were conducted with local area homes to identify the needs and

concerns of care home staff. o RN care managers develop relationships with each local care home where patients reside and meet

regularly with care home staff to improve communication. o The RN care managers also assess patients and identify gaps in care. They work with care

management team and individual physicians to address identified gaps. o Multidisciplinary teams consisting of RN Care Manager, physician, and pharmacist go out to 2 Adult

Care Homes every week and perform acute and follow up visits at the care home. The team works with the administrator of the Adult Care Facility to identify other patients at risk and to reduce barriers to cost effective care.

One large volume 646 practice is performing group medical visits for selected chronic care patients and results have been positive.

One network is piloting the 646 physicians visiting critically ill patients in the hospital to discuss treatment goals.

Nursing Home (NH) Initiative: Since 5% of the duals participating in 646 are in nursing homes, we have some networks piloting outreach to these patients.o One network has embedded care managers in nursing homes and has also embedded care

managers and pharmacists in hospitals to review hospital admission data and to target NH education regarding preventable readmits – fall prevention, dehydration, etc.

o The Palliative Liaison Advance Care Team (PlanAct) program uses an evidence-based approach to identify residents at high risk of death using a prognostic measure from the federally-mandated Minimum Data Set (MDS) that is required for completion in virtually every NH. Based on the findings and when appropriate, NH staff are supported by palliative care experts as they work with the identified residents, families, and healthcare providers to discuss and put into practice specific areas of end-of-life care. Outcomes are assessed though interviews with family caregivers.


Congestive Heart Failure (CHF) Initiative: One network has begun a CHF pilot with their largest 646 practice and a large Home Health agency. When a newly diagnosed CHF patient is scheduled to receive a home health visit, the network care manager and home health agency make a joint visit to the patient’s home. They meet with the patient to determine if the patient is a good candidate for a tele-monitoring device to be installed in the home. This device transmits the patient’s vital signs to the network care manager for monitoring. This program is designed to teach patients how to care for themselves, manage their CHF, and learn the warning signs of when it is best to contact their primary care provider or seek emergent care. Early detection and treatment may avoid unnecessary hospital admissions or emergency department visits.

Palliative Care Training: Palliative care offers improved control over symptoms such as pain, shortness of breath and anxiety. Palliative care includes but is not limited to care in the final phase of life. It can be combined with treatments meant to ameliorate the patient’s serious illness, at any stage of that illness. Along with symptom management, palliative care emphasizes open communication and emotional and spiritual support for both the patient and family. Patients and families have the right to discuss treatment options and make medical decisions that are in line with their goals. In this way, palliative care offers patients both increased autonomy and the best possible quality of life during serious illness. Community Care is providing training to the CCNC care managers identified in all networks. Advance care planning documents allow patients to record their treatment choices prior to the time urgent

clinical decisions are made. Community Care is providing training to network Care Managers in several domains of Palliative/End of Life

care. This training combines the principles of palliative care, adult education and quality improvement practice

change principles. This approach has the potential to engage and activate participants to become champions of patient communication, autonomy and attention to palliative care needs within their local practice network.

As the North Carolina Medicaid Program moves forward in exploring new delivery systems and payment models, it will be important to continue to strengthen the relationships with existing stakeholders while identifying opportunities to work with additional stakeholders.

V. Timeframe

North Carolina expects to utilize the twelve month planning grant to design and develop a strategic plan that changes, aligns and enhances the delivery of care to dual eligible population. Within the 12 month planning grant, North Carolina will engage actuarial consultants to assist in the payment reform analyses, to develop rate structures and budgets and to develop a shared savings strategy. Any needed State Plan Amendments will be written and hopefully approved prior to the end of the twelve month planning phase so that the implementation plan can begin.

Dedicated staff will coordinate the planning efforts and ensure that timelines and deliverables are tracked and met. A state level leadership group from all the stakeholder agencies will meet regularly to drive and support any needed policy changes. Communication specialists will be engaged to make sure that stakeholders are engaged and informed in the development process and that their input and feedback is actively secured and used. North Carolina will be able to implement a new and innovative delivery system for duals immediately following the twelve month planning phase.


VI. Budget

Project Director / Coordinator @ 100 % FTE – in charge of project management $ 95,000

Associate Project Director – in charge of stakeholder process & development $ 70,000

Part-time Administrative Assistant $ 20,000

Staff travel and expenses $ 10,000

Part-time communications and marketing consultant– develop plan design documents to be shared with stakeholders; define outreach program for providers and beneficiaries $ 80,000

Clinical / Behavioral / Pharmacy consultants to support the design of key components of theintegrated program $ 80,000

Program Consultants to support Medicaid policy and reimbursement revisions; and the development of needed State Plan Amendments $150,000

Data Analyses and Design Program Development to support the Informatics Center and Provider Portal in incorporating an Integrated Model; implement and purchase crossover claims and fiscal intermediary processing $225,000

Actuarial /Financial /Budgeting Consultants – to support the payment reform analyses; develop rate structure; develop a financial plan that aligns incentives for integrated care; develop budget; shared savings strategy $270,000

Total Budget $ 1 million

Notes: All project staff salaries include fringes and benefits.


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