14147.1.
For purposes of this article, the following definitions shall apply:(a) “Eligible program” means a nonprofit organization or entity, including a private hospital, or a unit of local government, including a public hospital or a county, that elects to participate in the pilot program developed pursuant to this article and that meets the criteria described in subdivision (c) of Section 14147.2.
(b) A “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 a chronic or life-threatening condition that requires management of symptoms, medications, health care, or changes in lifestyle or risk-related behaviors, which may include, but need not be limited to, HIV/AIDS, hepatitis, diabetes, heart disease, hypertension, emphysema, asthma, or cancer.
(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 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 interfere with the individual’s health or appropriate utilization of health services.
(4) The individual is currently experiencing homelessness.
(c) “Homelessness” means lacking a fixed, regular, or adequate nighttime residence or a primary nighttime residence that is a supervised publicly or privately operated shelter designed to provide temporary living accommodations or a public or private place not designed for, or ordinarily used as, regular sleeping accommodation for human beings.
(d) “Stakeholders” shall include, but are not limited to, the Frequent Users of Health Services Initiative, the Corporation for
Supportive Housing, the California Mental Health Directors Association, community clinic representatives, and other disciplines that represent the needs of frequent users of health services, as defined in subdivision (b).
14147.2.
(a) (1) The pilot program shall provide services to Medi-Cal beneficiaries in addition to an individual’s existing Medi-Cal benefits, 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.(2) The state shall provide for the nonfederal share of cost for services provided to individuals under the pilot program. These services may include, but need not be limited to, all of the following:
(A) Individualized, intensive face-to-face care coordination and case management.
(B) Money management services and education.
(C) Services to support adherence to medication.
(D) Transportation.
(E) Life skills training.
(F) Peer and recovery support.
(G) Prevocational
and vocational services.
(H) Employment support services.
(3) Nothing in this section shall preclude a local entity from contributing funds for the services listed in paragraph (2), or for other services.
(4) Care coordination and case management services may be provided by nonlicensed professional or paraprofessional staff who provide care coordination.
(b) The department shall implement the pilot in at least six eligible programs, as
defined in subdivision (a) of Section 14147.1, and in accordance with the criteria developed pursuant to subdivision (c).
(c) The selection of the eligible programs shall be based on criteria that shall be developed by the department, in consultation with stakeholders. The department may consult with existing frequent user projects in developing selection criteria. The criteria for participation as a program shall include at least all of the following:
(1) Demonstrated experience working with the frequent users of health services population.
(2) The capacity and administrative infrastructure to participate in the pilot program, including the ability to keep appropriate records and provide data on clients.
(3) Documented ability to provide or to link
clients with appropriate community-based services, including intensive, individualized, face-to-face care coordination, services to support adherence to medication, primary care, specialty care, mental health treatment, substance abuse treatment, peer and recovery support, permanent or transitional housing, transportation, money management, prevocational and vocational services, employment support, and benefits advocacy.
(4) A plan to offer services to a point-in-time caseload of at least 100 clients on a voluntary basis.
(5) Support of essential community hospitals, particularly hospitals serving a high proportion of Medi-Cal patients, such as public or private
disproportionate share hospitals.
(d) The pilot program’s initial enrollment goal shall be 2,500 Medi-Cal beneficiaries needing intensive services who are frequent users of health services, as defined in subdivision (b) of Section 14147.1. These beneficiaries may require less intensive services, or graduate completely from the program upon stabilization. The department may increase the total number of intensive services participants in the program if the department determines that, based on the data collected relating to, and beneficial outcomes resulting from, the initial implementation of the pilot program, expanding the number of intensive services participants is warranted.
(e) The department shall prepare, or contract for the preparation
of, an evaluation of the first two years of participant enrollment in the frequent users pilot program. The evaluation shall assess the outcomes of the pilot program, including, all of the following, to the extent that the information is available:
(1) The total number of program participants in the frequent user program.
(2) The total number of program participants who were Medi-Cal beneficiaries at the time of enrollment and the number of beneficiaries who did not remain enrolled in the program for at least 12 continuous months.
(3) All of the following information, with respect to participants who were Medi-Cal beneficiaries at the time of enrollment in the program and during the 12 months
immediately preceding enrollment, and who remained enrolled in the program for at least 12 continuous months:
(A) The frequency of emergency department visits during the 12 months prior to enrollment in the program and the associated costs to Medi-Cal.
(B) The frequency of emergency department visits during the 12 months after program enrollment and the associated costs to Medi-Cal.
(C) The total number of inpatient days during the 12 months immediately preceding enrollment and the associated costs to Medi-Cal.
(D) The total number of inpatient admissions during the 12 months after enrollment in the program and the associated costs to Medi-Cal.
(E) The total number of inpatient days during
the 12 months immediately preceding enrollment and the associated costs to Medi-Cal.
(F) The total number of inpatient days during the 12 months after program enrollment and the associated costs to Medi-Cal.
(4) All of the following information, with respect to the total number of participants who were Medi-Cal beneficiaries at the time of enrollment in the program, and during at least 12 months immediately preceding the enrollment, and who remained enrolled in the program for at least 24 continuous months:
(A) The frequency of emergency department visits during the 12 months immediately preceding enrollment in the program and the associated costs to Medi-Cal.
(B) The frequency of emergency department visits during the 24 months after enrollment in the
program and the associated costs to Medi-Cal.
(C) The total number of inpatient admissions during the 12 months immediately preceding enrollment in the program and the associated costs to Medi-Cal.
(D) The total number of inpatient admissions during the 24 months after enrollment in the program and the associated costs to Medi-Cal.
(E) The total number of inpatient days during the 12 months immediately preceding enrollment and the associated costs to Medi-Cal.
(F) The total number of inpatient days during the 24 months after program enrollment and the associated costs to Medi-Cal.
(5) The total number of program participants who have accrued the highest 10 percent of Medi-Cal reimbursable
expenses during any one 12-month period of program enrollment, the total average costs per person during that period, and the conditions for which each was treated.
(6) The conditions present upon enrollment of participants.
(7) The number of Medi-Cal beneficiary participants who used primary care services, and, if the information is available, behavioral health services, and the frequency of the usage of primary care and behavioral health services after enrollment.
(8) If available, the number of participants who were homeless upon enrollment and the number of participants who remained homeless 12 months after program enrollment.
(9) Of the services identified in subdivision (a) of Section 14147.2, the frequency each service was provided and
reimbursed, the reimbursement rate for each service, and total expenditures for each service.
(10) Barriers that program administrators reported and the department encountered.
(f) The department shall only seek out and utilize private funds to fund the evaluation. The department shall report to the appropriate policy and fiscal committees of the Legislature upon the completion of the evaluation.
(g) The pilot program shall operate for a period of three years
commencing upon receipt of federal approval.