The Health Services Agency (HSA) requests that your Board: ratify submission of an application for a Whole Person Care (WPC) Pilot grant program administered by the California Department of Health Care Services (DHCS); authorize HSA to proceed with acceptance of an award for a $20.8 million project and execute related grant agreements; and direct the County Administrative Office to proceed with additions to the fiscal year 2017-18 County Budget for related new staffing and services.
‘Whole Person Care’ (WPC) Pilot Programs
Authorized by the federal Centers for Medicare and Medicaid Services (CMS), WPC is a five-year program (January 2016 - December 2020) under California’s Medi-Cal 2020 Waiver. The WPC has been developed to test locally-based initiatives that coordinate physical health, behavioral health, and social services for vulnerable Medi-Cal beneficiaries who continually sustain poor outcomes as high users of multiple health care systems. Through collaborative leadership and systematic coordination among public and private entities, WPC pilot grants identify target populations, share data between systems, coordinate care in real time, and evaluate individual and population health progress.
DHCS is the lead State agency responsible for the planning, implementation and evaluation of the Medi-Cal 2020 Waiver and WPC grants. In May 2016, DHCS released the first round of WPC applications for counties to compete for the funding. In late January 2017, DHCS released the second round of WPC applications with the deadline of March 1, 2017. Provided for your Board’s review, is an information packet containing the WPC grant application requirements (Attachment 1). Due to the short turnaround timeline, and the need to engage appropriate stakeholders to prepare the application, budget match, and letters of support, HSA regrets that it did not have enough time to obtain your Board’s prior authorization within the four scheduled Board meetings in January and February 2017.
Under DCHS’s guidelines for WPC applicants:
· The “Lead Entity” for a WPC pilot must either be a county, a city and county, a health or hospital authority, a designated public hospital, or a district/municipal public hospital, a federally recognized tribe, a tribal health program operated under a Public Law 93-638 contract with the federal Indian Health Services, or a consortium of any of the above entities.
· Local participating Medi-Cal managed care health plans are required to participate in the pilot.
· Letters of support from key stakeholders must be included and key partners must be identified and their roles must be clearly defined in the WPC program.
· The “Lead Entity” must provide 50% cash match for the total budget request via an intergovernmental transfer of public funds from a governmental entity to DHCS. The “Lead Entity” must certify that the cash match funding is public funds which qualify for federal financial participation under relevant federal Medicaid law, including that the funds are not derived from impermissible sources such as recycled Medicaid payments, federal funds excluded from use as state match, impermissible taxes, and non-bona fide provider donations.
· WPC money cannot include payment for services currently reimbursable through Medicaid, and it cannot be used to fund local responsibilities for health care or social services that are mandated by state or federal laws, or to fund services for which state or federal funding is already provided.
· WPC money cannot be used to pay for non-Medicaid individuals or for room and board/rental housing costs.
· If awarded, grant payments are made based on meeting proposed measureable outcomes for Administrative Infrastructure need, Delivery Infrastructure need, a Fee for Services model, a Bundled Per/Member Per/Month Services model, Pay for Metric Reporting, and Pay for Metric Outcomes Achievement.
Santa Cruz County’s WPC Project
After much thorough review and deliberation, HSA was able to meet the deadline and submitted a WPC proposal entitled “Cruz to Health-Data Connect”, with a project amount of $20.8 million for the duration of the project ending December 2020. WPC grants require a 50% local match, which HSA is providing from Mental Health Services Act and behavioral health realignment funds.
The target population, up to 1,000 unduplicated adult individuals over the life of the pilot project, will be comprised of Santa Cruz Medi-Cal beneficiaries who:
· Have repeated incidents of avoidable emergency room use, hospital admissions, crisis and acute psychiatric hospitalizations, or nursing facility placement; and/or
· Have been in a locked long-term institution(s) for mental illness; and/or
· Have two or more chronic health disorders involving five or more medications actively prescribed from the following categories that represent high-cost chronic health conditions: antidepressants, antipsychotics, mood stabilizers, diabetes medications, antihypertensives, cholesterol lowering medications, inhaled corticoseteroids and bronchodilators, seizure medications, and anticoagulants; and/or
· Currently experiencing homelessness; and/or are at risk of homelessness and require intensive supportive housing supports to live in the community due to their mental illness, substance use disorder, and co-occuring health conditions.
The goal of HSA’s ‘Cruz to Health-Data Connect’ WPC project is to combine several evidence-based approaches to more effectively and efficiently provide care to individuals with a mental illness, substance use disorder, and co-occurring health condition who are homeless or are at risk for homelessness in the community. The project is designed to support participants to live in the least restrictive setting and improve their behavioral health and other health condition outcomes, improve community tenure, reduce costly hospitalizations and visits to the emergency department, and improve these individuals’ lifespans.
To address the needs of this population, four key components were incorporated into HSA’s model:
1. A multidisciplinary team which will include mental health clinicians, primary care clinicians, occupational therapists, nursing staff, medical assistants, housing outreach peer staff, and case managers.
2. The evidence-based practice of supported housing with co-occurring behavioral health and other health conditions to include assistance in locating and securing housing and in-home supports and services from the multidisciplinary team.
3. An integrated health model that will allow in-home remote access monitoring and care for participants with co-occurring health conditions such as diabetes, obesity, hypertension, and chronic obstructive pulmonary disease. By providing electronic remote access monitoring devices in the home, the participant can relay specific health and behavioral health data back to nursing staff who will triage and communicate that information to the treatment team in order to effectively address issues in real time with the individual, provide educational content that supports coping strategies, and monitor outcomes data over time.
4. Inclusion of family members and peers trained in the evidence-based practice of Intentional Peer Support to provide independent living skills-building and social engagement and modeling for community integration to the individuals living in their homes or other community placements. The peers will assist in building natural supports while facilitating individualized recovery goals.
Housing rentals will be provided using traditional funding through federal programs administered by the U.S. Department of Housing and Urban Development (HUD), ‘Shelter Plus Care’ and Veterans Affairs Supportive Housing ‘VASH’ vouchers, along with funds from the WPC grant for rental and security deposits and a master leasing program on behalf of the program participants, that designates a local non-profit entity to acquire and hold the lease for the apartments. Clients will receive a variety of services and interventions, including housing transition assistance, housing management and supports, peer support services, and health care monitoring via remote device technology in the client’s home.
Tentative Grant Award
HSA is pleased to inform your Board that in early May 2017, DHCS notified HSA with tentative preliminary approval of HSA’s $20.8 million project pending final approval from CMS, and asked HSA to complete necessary programmatic steps to launch the program effective July 1, 2017. In June, HSA expects to receive final award documents, and the entire approved application would be released and published by the State. HSA will include the grant award and new staffing in the FY 2017-18 Last Day Supplemental Budget.
In order to implement this WPC project, HSA proposes to utilize a combination of 14 FTE’s in new limited-term County staffing, and 13.5 FTE’s of contracted staff from local Community Based Organizations (CBO’s). The new County positions will include 13.0 FTE’s in HSA and 1.0 FTE in the Probation Department, for inclusion in the fiscal year (FY) 2017-18 HSA’s and Probation’s respective Last Day Supplemental Budgets. As time is of the essence, HSA will work with the Personnel Department to initiate position classification and recruitment efforts in June, with hiring to be contingent upon your Board’s approval of the Last Day Supplemental Budget. HSA plans to return to your Board in FY 2017-18 to present proposed agreements with the CBO’s for the contracted staffing.
HSA’s WPC project is coordinated with multiple stakeholders participating in roles such as program governance and evaluation, referral of project clients, coordination of primary and behavioral health care delivered, housing support, and provision of program data-sharing and local match funding. The project is primarily managed by a collaboration between the two HSA divisions of Behavioral Health and Clinics Services. This project also engages the HSA Public Health Division’s agency of Emergency Medical Services, as well as the County’s Human Services Department and Probation Department. Additional participants are local health care and related partners including the Central California Alliance for Health, Dignity Health Dominican Hospital, Watsonville Community Hospital, Housing Authority of Santa Cruz County, the Health Improvement Partnership of Santa Cruz County, and the Santa Cruz Health Information Exchange. Twenty letters of support from the project partners and additional interested parties were submitted to DHCS with HSA’s application (Attachment 2).
In summary, HSA is pleased to inform your Board of the ‘Whole Person Care’ Pilot Program opportunity which offers strong collaboration between multiple facets of the community involving criminal justice, housing, hospitals, the local Medi-Cal managed care health plan, primary and behavioral health, and local health information exchange systems to further enhance necessary services for our most vulnerable population. HSA’s grant application has been received favorably by the California Department of Health Care Services, and confirmation of their grant award is anticipated soon for the $20.8 million project scheduled to begin on July 1, 2017.
It is, therefore, RECOMMENDED that your Board:
1. Ratify submission of an application for Whole Person Care (WPC) Pilot grant program administered by the California Department of Health Care Services (DHCS);
2. Authorize the Health Services Agency (HSA) to proceed with acceptance of a award for a $20.8 million grant project from the WPC program and execution award agreement, with award funding to be included in the fiscal year 2017-18 Last Day Supplemental Budget of HSA and the Probation Department, contingent upon DHCS approval of HSA’s WPC grant application; and
3. Direct the Health Services Agency to return to your Board in September with an update regarding program implementation.