integrate medical homes into the service delivery system.
Reimbursement Reform Options: As a part of reforming the Medi-Cal reimbursement structure, California needs to make a significant investment in the program by providing additional reimbursement to providers who agree to become medical homes for this population. The state will also need to reform how it reimburses providers to assure beneficiaries have access to needed services. Some reimbursement reform options include:
Increased reimbursement for primary care providers that could be provided either through rates or reimbursement for case management;
Better integration of medical homes into FQHCs that could also include increased utilization of specialty care;
Better utilization of public hospitals and clinics to apply the lessons learned from the coverage initiative to people on Medi-Cal;
Integration of the mental health program with public hospitals and clinics and FQHCs to make mental health and alcohol and drug screening and treatment a component of medical care; and
Improved access to specialty care. Participants would need assured access to these services. Increasing reimbursement rates for specialty providers, and perhaps targeting those located in underserved areas, could increase participation.
Expanded Service Reform Options: DHCS would need to work with vendors, local entities such as counties, or health plans to leverage their knowledge and resources to design and implement a medical home program. Any approach would have to build upon existing networks of providers and the safety net. A medical home program should include the following:
Health information technology capacity to identify and stratify the covered population by risk, using predictive modeling and other tools to anticipate needs and target appropriate levels of intervention to match need;
Disease management and care coordination for target sub-populations, across all co-morbid conditions including behavioral health, with in-person and other interventions;
24-hour toll-free access for beneficiaries to medical advice/nurse hotline;
Consumer education to support informed self-management and outreach to encourage participation in care management;
Assistance with, tracking, and follow-up on referrals to other medical or social support services and assistance in reducing rates of missed appointments;
Communication with consumers, family caregivers and providers to facilitate more effective utilization of services and improved health outcomes;
Provider education regarding evidence based practices, available services, and quality improvement strategies;
Formal performance improvement process to systematically identify, address and measure areas for on-going quality improvement; and
An electronic health record for providers and facilitated electronic information exchange among providers in the network and between primary care and specialty providers.
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