California Assembly Bill AB2266 Amended / Bill

 BILL NUMBER: AB 2266AMENDED BILL TEXT AMENDED IN ASSEMBLY APRIL 17, 2012 AMENDED IN ASSEMBLY MARCH 20, 2012 INTRODUCED BY Assembly Member Mitchell FEBRUARY 24, 2012 An act to add Article 3.9 (commencing with Section 14127) to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, relating to Medi-Cal. LEGISLATIVE COUNSEL'S DIGEST AB 2266, as amended, Mitchell. Medi-Cal:  Enhanced  Health Homes for  Enrollees   Frequent Hospital Users  with Chronic Conditions. Existing law provides for the Medi-Cal program, which is administered by the State Department of Health Care Services, under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid Program provisions. Existing federal law authorizes a state, subject to federal approval of a state plan amendment, to offer health home services, as defined, to eligible individuals with chronic conditions. This bill would require the department, upon approval of a state plan amendment, to establish a program in at least 5 counties to provide health home services to frequent  hospital  users  of health services  , as  defined   prescribed  .  This bill would require the department to prepare, or contract for the preparation of, an evaluation of the program, and to complete the evaluation and submit a report to the appropriate policy and fiscal committees of the Legislature within   18 months after designated providers have been selected and have begun to seek payment.  Vote: majority. Appropriation: no. Fiscal committee: yes. State-mandated local program: no. THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS: SECTION 1. The Legislature finds and declares all of the following: (a) The Health  Home   Homes  for Enrollees with Chronic Conditions option  (Health Homes option)  under Section 2703 of the federal Patient Protection and Affordable Care Act  (Affordable Care Act)  (42 U.S.C. Sec. 1396w-4)  is   offers  an opportunity for California to address  the needs of people who frequently use emergency departments for reasons that could have been avoided with earlier or primary care, as well as the overlapping population of people experiencing chronic homelessness   complex, cooccurring, chronic, and disabling health conditions, as well as social determinants of poor health outcomes and high costs among Medi-Cal beneficiaries  . (b) Almost half of  frequent   the people who frequently use the  emergency department  users   for reasons that could have been avoided with earlier or primary care  are homeless.    People who are chronically homeless are vulnerable to frequent hospitalization.  Frequent users who are homeless face significant difficulties accessing regular or preventive care and complying with treatment protocols  with   , having  no place to store medications, an inability to adhere to a healthy diet or maintain appropriate hygiene, frequent victimization, and a lack of rest to recover from illness. Homeless Medi-Cal enrollees will, in fact, continue to use costly acute care services and actually increase their inpatient days, even if receiving medical home services to reduce their return to the hospital. (c) Increasingly, health providers are partnering with community  behavioral health,  social services  or   , and  housing providers to offer a person-centered interdisciplinary system of care that includes intensive paraprofessional care coordination or case management  , often in supportive housing  . Programs that offer intensive  and comprehensive  care coordination to frequent  emergency department   hospital users integrate primary care, behavioral health care, and social services, and facilitate coordination of care among health systems, making this model an ideal health home that fosters a "whole person" orientation. (d) Data show that programs providing intensive  case management and  care coordination, including connecting  homeless   to and sustaining  people  to   in  housing, decrease Medicaid costs within a year  by reducing avoidable emergency department visits, hospital admissions, and readmissions  . A randomized study of chronically homeless frequent users receiving intensive  care coordination   case management  in housing demonstrated  that every 100 participants experienced 270 fewer hospitalizations, 116 fewer emergency department visits, and 2,000 fewer nursing home days   decreases in hospital admission rates of 46 percent, hospital days of 46 percent, and emergency department visits of 36 percent after 18 months of intervention, compared to a control group receiving usual care  . Medi-Cal beneficiaries participating in foundation-funded frequent user programs experienced reductions in Medi-Cal  hospital  costs of three thousand eight hundred forty-one dollars ($3,841) per beneficiary after one year and seven thousand five hundred nineteen dollars ($7,519) per beneficiary per year after two years, while drastically improving clinical outcomes.  (e) Additionally, the Massachusetts Office of Medicaid, as another example, reported that its Medicaid Program offering intensive interdisciplinary services and connecting chronically homeless individuals to housing reduced Medicaid costs by 67 percent for a total cost decrease of nine thousand eight hundred ten dollars ($9,810) per resident, even when considering the costs of housing.   (f) Federal guidelines allow the state to access enhanced federal matching rates under the Health Homes option for multiple target populations to achieve more than one policy goal.  SEC. 2. Article 3.9 (commencing with Section 14127) is added to Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to read: Article 3.9.  Enhanced  Health  Home  Homes  for  Enrollees   Frequent Hospital   Users  with Chronic Conditions 14127. For the purposes of this article, the following definitions shall apply: (a) "Department" means the State Department of Health Care Services.  (b) "Eligible program" means a team comprised of a nonprofit organization or entity, including a private hospital, a public hospital or county, a community clinic, and social service providers, that elects to participate in the program pursuant to this article and that meets the criteria described in federal guidelines. For the purposes of this article, "eligible program" shall include health home teams that incorporate social service providers.   (b) "Eligible individual" means an individual who meets the criteria defined by the department consistent with subdivision (c) of Section 14127.1 for eligibility for enhanced health home services identified in subdivision (b) of Section 14127.2.   (c) "Enhanced health home" means a designated provider, such as a physician, clinical practice or clinical group practice, rural health clinic, community health center, community mental health center, home health agency, or any other entity or provider, operating or proposing to operate in coordination with a team of health care professionals, such as physicians, nurse care coordinators, nutritionists, social workers, behavioral health professionals, and paraprofessionals, that satisfies all of the following:   (1) Meets the criteria described in federal guidelines.   (2) Offers a whole person approach.   (3) Coordinates or proposes to coordinate services for all of the needs of eligible individuals.   (4) Elects to participate in the program pursuant to this article.   (5) Offers services in a range of settings, including the eligible individual's home.   (c)  (d)  "Federal guidelines" means all federal statutory guidance, and all regulatory and policy guidelines issued by the federal Centers for Medicare and Medicaid Services regarding the Health Homes for Enrollees with Chronic Conditions option under Section 2703 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 1396w-4), including the State Medicaid Director Letter issued on November 16, 2010.  (d) "Frequent user of health services" means an adult who has undergone emergency department treatment on five or more occasions in the past 12 months or on eight or more occasions in the last 24 months, who would benefit from the provision of multidisciplinary services, and who has two or more of the following risk factors:   (1) On one or more occasions within the last 24 months, the individual was diagnosed with two or more chronic conditions that require management of symptoms, medications, health care, or changes in lifestyle or risk-related behaviors. These conditions may include specific conditions the department identifies based on data collected pursuant to Section 14127.1.   (2) On one or more occasions within the last 24 months, the individual was diagnosed, or, in the judgment of an emergency department physician, would likely be diagnosed, if provided a mental assessment, with an Axis I or Axis II mental disorder identified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.   (3) On one or more occasions within the last 24 months, the individual was diagnosed, or, in the judgment of an emergency department physician, would likely be diagnosed, if provided an assessment, with a substance use disorder, including substance dependence and substance use problems, that interferes with the individual's health or appropriate utilization of health services.   (4) The individual is homeless.  (e) "Homeless" has the same meaning as that term is defined in Section 91.5 of Title 24 of the Code of Federal Regulations.  An adult is "chronically homeless" if he or she has a disability and has experienced homelessness for longer than a year, or for four or more episodes over three years.   (f) "Stakeholders" includes, but is not limited to, the Frequent Users of Health Services Initiative program participants, other frequent user programs the department selects, the Corporation for Supportive Housing, the California Mental Health Directors Association, community clinic representatives, the California Hospital Association or the California Association of Public Hospitals, and representatives from other disciplines that represent the needs of frequent users of health services.  14127.1. (a) No later than  July 1, 2013   January 1, 2014  , the department shall do all of the following:  (1) Collect data to determine conditions that are most prevalent among frequent users of health services, as defined in subdivision (d) of Section 14127, whose high costs could be avoided with more appropriate care.   (2)   (   1)  Design,  in consultation with stakeholders   with opportunity for public comment  , a program to provide  enhanced  health home services to  frequent users of health care services   persons at high risk of avoidable and frequent use of hospital services due to   complex cooccurring health and behavioral health conditions  .  (2) Upon a request for proposals process, select providers in accordance with subdivision (c) of Section 14127.2, as designated providers working in coordination with health care providers under the Health Homes option state plan amendment.  (3) Submit any necessary  application   applications  to the federal Centers  of   for  Medicare and Medicaid Services for a state plan amendment under  Section 2703 of the federal Patient Protection and Affordable Care Act (42 U.S.C. Sec. 1396w-4), the Health Homes for Enrollees with Chronic Conditions option,   the Health Homes option  to provide  enhanced  health home services to Medi-Cal beneficiaries  , to newly eligible Medi-Cal beneficiaries upon Medicaid expansion under the Affordable Care Act,  and  Low Income Health Program (LIHP)   ,   if   applicable, in counties with Low Income Health Programs (LIHPs) willing to match federal funds, to  enrollees  who are frequent users of health services   of the LIHP  .  (b) The department shall commence implementation of a program in accordance with the Health Homes for Enrollees with Chronic Conditions option (42 U.S.C. Sec. 1396w-4) on the first day of the third month following the month in which federal approval of the state plan amendment sought pursuant to subdivision (a) is received.   (c) The program established pursuant to this article shall provide services to Medi-Cal beneficiaries in addition to an individual's existing Medi-Cal benefits, and, in counties with LIHPs that are willing to provide state matching funds, to enrollees of the LIHP implemented through California's Bridge to Reform Section 1115(a) Medicaid Demonstration, and shall be designed to reduce a participating individual's use of hospital emergency departments when more effective care, including primary, specialty, and social services, can be provided in less costly settings.   (b) The program established pursuant to this article shall provide services to Medi-Cal beneficiaries, to newly enrolled Medi-Cal beneficiaries upon implementation of Medicaid expansion under the Affordable Care Act, and, if applicable, in counties with a LIHP established under California's Bridge to Reform Section 1115(a) Medicaid Demonstration implemented on November 1, 2010, willing to match federal funds, to enrollees of the LIHP. The program established pursuant to this article shall be designed to reduce a participating individual's avoidable use of hospitals when more effective care, including primary and specialty care, and social services, can be provided in less costly settings.   (c) The department shall seek, to the extent permitted by federal law, to define the population of eligible individuals experiencing both of the following:   (1) Two or more of the following current diagnoses:   (A) Mental health disorders identified by the department as prevalent among frequent hospital users.   (B) Substance abuse or substance dependence disorders.   (C) Chronic or life-threatening medical conditions identified by the department as prevalent among frequent hospital users.   (D) Significant cognitive impairments associated with traumatic brain injury, dementia, or other causes.   (2) Two or more of the following indicators of severity:   (A) Frequent inpatient hospital admissions, including long-term hospitalization for medical, psychiatric, or substance abuse related conditions.   (B) Excessive use of crisis or emergency services or inpatient hospital care with failed linkages to primary care or behavioral health care.   (C) Chronic homelessness.   (D) History of inadequate follow-through, related to risk factors, with elements of a treatment plan, including lack of follow through in taking medications, following a crisis plan, or achieving stable housing.   (E) Two or more episodes of use of detoxification services.   (F) Medication resistance due to intolerable side effects, or illness interfering with consistent self-management of medications.   (G) Self-harm or threats of harm to others.   (H) Evidence of significant complications in health conditions.  14127.2. (a) In accordance with federal guidelines, the state may limit the availability of services geographically, but shall  select designated providers to  implement the program in at least five counties; provided  , however,  that providers meet  federal  criteria  identified in subdivision (c)  in each county designated.  Providers may include nonlicensed professional or paraprofessional staff, including social workers.  (b) (1)  Services   Subject to federal approval, services  provided under the program established pursuant to this article shall include  , but need not be limited to,   individual, multidisciplinary services and supports available for eligible individuals to decrease hospitalizations and crisis episodes, reduce medical risks, and increase functioning to achieve and maintain rehabilitative, resiliency, and recovery goals. At least 60 percent of the services   shall be provided in natural settings, including services delivered in an eligible individual's home. Services shall consist of  all of the following: (A)  Individualized   Comprehensive and individualized intensive face-to-face outreach,  care coordination,   engagement,  and case management.  (B) Money management services and education.   (B) Care coordination and health promotion, including connection to medical, mental health, and substance abuse care.   (C) Comprehensive transitional care from inpatient to other settings, including appropriate follow-up.   (D) Individual and family support, including authorized representatives.   (E) Referral to other relevant community and social services supports.   (F) Health information technology to identify eligible individuals and link services, if feasible and appropriate.   (G) Prevention and therapeutic interventions to facilitate stabilization.   (H) Illness self-management.   (C)   (   I)  Transportation  to appointments needed to manage health needs  .  (D) Life skills training.   (E)   (   J)  Peer and recovery support.  (F) Prevocational and vocational services.   (G) Employment support services.   (H)   (   K)  Housing location  and tenancy support  services for participants who are homeless or unstably housed. (2) Beneficiaries may require less intensive services or graduate completely from the program upon stabilization.  (c) The selection of the eligible programs shall be based on criteria that shall be developed by the department pursuant to federal guidelines and in consultation with stakeholders. The criteria for participation as a program shall include at least all of the following:   (c) The department shall select designated providers operating with a team of health care professionals that have all of the following:   (1) A designated lead provider that is a community clinic, a provider of mental health services pursuant to the Adult and Older Adult Mental Health System of Care Act (Part 3 (commencing with Section 5800) of Division 5), or a hospital.   (1)   (   2)  Demonstrated experience working with  the  frequent  hospital  users  of health services population   , with documentation of experience reducing emergency department visits and hospital inpatient days among the population served  .  (3) Demonstrated experience working with people experiencing chronic homelessness.   (2)   (   4)  The capacity and administrative infrastructure to participate in the program, including the ability to meet requirements of federal guidelines  identified in the State Medicaid Director letter dated November 16, 2010, regarding Health Homes for Enrollees with Chronic Conditions  .  (3)   (   5)  Documented ability to provide or to link clients with appropriate community-based services, including intensive individualized face-to-face care coordination, primary care, specialty care, mental health treatment, substance abuse treatment, peer and recovery support, permanent or transitional housing,  and  transportation  , money management, prevocational and vocational services, and employment support  .  (4) A plan to offer services to a point-in-time caseload of at least 100 clients on a voluntary basis.   (6) Experience working with supportive or other permanent housing providers.   (5)   (   7)  Support of essential community hospitals, particularly the hospital or hospitals serving a high proportion of Medi-Cal patients, such as disproportionate share hospitals.  (8) A viable plan, with roles identified among providers of the enhanced health home, to do all of the following:   (A) Reach out to and engage frequent hospital users and chronically homeless eligible individuals.   (B) Connect eligible individuals who are homeless or experiencing housing instability to permanent housing, including supportive housing.   (C) Ensure eligible individuals receive whatever integrated services are needed to access and maintain health stability, including medical, mental health, and substance abuse care and social services to address social determinants of health.   (D) Track, maintain, and provide outcome data to the evaluator described in Section 14127.4.   (E) Identify appropriate funding sources for the nonfederal share of costs of services for the first eight quarters of implementation of the program.   14127.3. (a) The state shall provide for the nonfederal share of costs for services provided to individuals under this article. (b)   14127.3.   (a)  This section shall not be construed to preclude local entities, health plans, or foundations from contributing the nonfederal share of costs for services provided under this program.  (c)   (   b)  This article shall not be construed to limit the department in targeting additional populations or creating additional programs under the Health Homes  for Enrollees with Chronic Conditions  option. 14127.4. (a) The department shall prepare, or contract for the preparation of, an evaluation of the  frequent users  program  identified in this article  . The department shall seek out and utilize only private funds to fund the evaluation. The department, within 18 months after  programs   designated providers  have been selected and have begun to seek  reimbursement   payment  , shall complete the evaluation and submit a report to the appropriate policy and fiscal committees of the Legislature. (b) The requirement for submitting the report imposed under subdivision (a) is inoperative four years after the date the report is due, pursuant to Section 10231.5 of the Government Code. 14127.5. This article shall be implemented only if federal financial participation is available and the federal Centers for Medicare and Medicaid Services approves the state plan amendment sought pursuant Section  14427.1   14127.1  , and only to the extent  nonstate funds   non-General Fund moneys  are available for use as the nonfederal share during the first eight quarters of implementation.