"When you look at some of the characteristics of the dual eligibles, in the under 65 population, 66 percent have only a chronic condition and have no functional impairments. But as you move up to the older ages, there’s fewer frailty and a bit more of the chronic conditions," according to Dr. Timothy Schwab, chief medical officer of SCAN Health Plan. SCAN has a strategic approach to serving the dual eligible market, and Dr. Schwab recently discussed how they get this population to complete health assessments as well as the role of case managers in deciding who needs nursing home services. He also discusses how case managers work with the most extreme health condition cases.
Question: SCAN-risk stratifies individuals to determine those at highest risk, using HRAs, claims data and other assessment tools. How does SCAN encourage or incent completion of HRAs and other assessments in what can sometimes be a transient or hard-to-reach population?
Response: Getting completion of the HRA instrument is a challenge in any population, but more so in a very diverse population like the dually eligible. We initially mail our HRA to all new members. Then we follow up with reminder postcards. If we still don’t receive a response, we have a shortened risk assessment form that we ask them to complete through telephonic interactive voice response (IVR). Even with that, we still probably have a 30 percent failure rate to get the HRA done in a timely fashion.
We try to supplement that with information from our physicians. On the first visit to the physician, we can gather information and ultimately supplement it with our claims data on both the medical side and importantly the pharmacy side. We get a lot of valuable information, which makes up for people who don’t complete the HRA.
There are two groups that usually don’t complete it. The first is the group in long term institutions, like nursing homes. There's a low response rate there. We also have a lower response rate in populations with mild dementia who are living on their own. But we also have a fairly low response rate from very healthy individuals. It’s important to recognize in the dual population that there are a group of duals that are relatively healthy. The only reason they’re a dual is because of financial conditions qualifying them for that. They could be out and about and just not concerned about completing the HRA.
We do not currently provide incentives for the general population to complete the HRA. We have tried some minor incentives with subsets of the population; for example, years ago with our diabetic population we offered a small gift of a foot care program if they completed a mini risk assessment. But in general, we haven’t found it effective.
Question: What percentage of your dual eligibles require disability support and what particular challenges would a case manager working with this subset of beneficiaries encounter?
Response: For our over 65 dual population, about 40 percent are what we classify as nursing facility level of care, or individuals who live in the community but have deficiencies in usually three or more activities of daily living (ADLs). They are frequently getting services for some of those deficiencies and are at high risk of ending up in a nursing home for long-term care, unless interventions are placed.
Of that 40 percent, probably about half are getting some sort of home-based services that are non-Medicare covered; things like personal care, homemaking, bathing assistance, and transportation assistance. For our case managers to make these assessments, do the in-home visits, and develop a care plan, we focus on hiring social workers, geriatric social workers and geriatric nurse practitioners. We spend a lot of time training them, both in how to identify the needs in the home, and how to identify the needs when talking with the caregiver, who is frequently an important part of this conversation.
We also offer on the job training for working with the rest of the team when they present these cases at our team meetings and the interdisciplinary care team meetings.
Question: How can care managers work with the most extreme cases that have multiple physical health and behavioral health, chronic and acute conditions?
Response: Those are the tough ones to work with. The first step is to find the right care manager for that individual. For example, if the primary issue is behavioral health, choose a care manager that excels in behavioral healthcare. That care manager then works with others to resolve the other issues. These people will require more time. You may also need to engage the help of the personal care workers or those in the home, so that they become both the physician and the care manager’s eyes and ears there. Teach them ways to pick up very subtle changes or differences in that person so that you can quickly provide new interventions if the person starts to show signs of deterioration. It’s a classic example of ‘one size doesn’t fit all;’ if your model says we will contact an individual monthly, some may need weekly and some may need daily contact. You may need to figure out ways to get that contact in an easy, efficient way for that individual.