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Medicare/Medicaid Integration Program

Oregon

Project Overview

General Approach & Current Status: The Oregon Department of Human Services (ODHS) in partnership with Multnomah County Aging and Disability Services (ADS) and Washington County Department of Aging and Veterans Services, is implementing a care coordination model to better serve long-term care clients with chronic conditions and functional dependencies. Care coordination is seen as an initial approach to more integrated care for Medicaid/Medicare Dual Eligible clients.

The initial demonstration pilot is being implemented at selected branches of the above two counties. The demonstration project evolved from primary interests and partnership experiences of Seniors and People with Disabilities (SPD) of ODHS, Multnomah ADS and Washington Aging Services in the area of coordinated care in an environment of interagency partnership.

SPD has worked with local partners in formulating a model to incorporate the care coordination for long-term care clients with chronic conditions. This model allows ADS offices to address the appropriate needs or issues identified by the local partners. This arrangement also allows SPD to use the existing resources of contract nurses to coordinate care.

The care coordination team model is based on a care coordination strategy through team case management. Core teams comprised of branch case managers, contract nurses, clients or their representatives, formal and non-formal caregivers, exceptional need care coordinator (ENCC) and physicians have now formed at local branches. ENCC representation is determined by clients' enrollment with Oregon Health Plan managed care providers.

Training on the principal areas of self-help, client-centered care planning, team building and various chronic health management issues is an important part of this demonstration project. Training has been customized to meet local needs.

Evaluation is another important component of this project. The project evaluation will be conducted in three outcome sub-groups: client, team and system. The client-specific outcomes include improvement in client's actual and self-perceived health, functional status, increased satisfaction with services, increased self-management and reduced or stabilized medical and social risks. The team-specific outcomes include measures of team collaboration, improvement in case managers' job satisfaction. The system-specific outcomes include reduced net acute care service utilization and improvement in perceived satisfaction of service providers.

Oregon has selected a contractor to link state Medicaid cost, utilization, and assessment data with Medicare data. The contractor will also undertake analyses of eligibility, utilization, enrollment, and cost patterns by important predictors (functional status, geographic location, age etc.). The analysis will also assist future financing and actuarial efforts.

Waivers: N/A

Eligible Population: Dual eligible Oregonians (both seniors and adult disabled) that utilize Medicaid long-term care services. The target population from the pilot consists of all senior and disabled long-term care Medicaid clients 18 years and older (with or without Medicare) who are not primarily case managed by Mental Health and Developmental Disabilities Services Division (MHDDSD). The majority of those without Medicare are pre-duals in the process of becoming Medicare eligible.

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