Archive for the ‘Dual Eligibles’ Category

AltaMed Constructs Business Case for Care Coordination Team

May 19th, 2015 by Patricia Donovan

The AltaMed multidisciplinary care team targets dual eligibles with multiple chronic conditions and functional and cognitive impairments.

When the largest FQHC in the country set out to quantify the contributions of its multidisciplinary care team, it found the concept didn't fit neatly into return on investment models.

So at budget time this year, leaders of AltaMed Health Services Corporation's care coordination model for its highest risk patients identified seven performance metrics to present to its CFO, explained Shameka Coles, AltaMed's associate vice president of medical management, during A Comprehensive Care Management Model: Care Coordination for Complex Patients, a May 2015 webinar now available for replay.

The evidence that ultimately secured funding for the care coordination project's next phase included the model's impact on specialty costs, emergency room visits, and HEDIS® measures, among other factors.

These were all areas examined early on, back in phase one, when the care coordination team set a number of strategic goals that aligned with the corporation's five pillars: service, quality, people, community and finance.

Rolled out in four phases beginning in July 2014, the model is aimed at AltaMed's dually eligible population— Medicare-Medicaid beneficiaries with high utilization, multiple chronic conditions, and multiple functional and cognitive impairments, Ms. Coles explained.

Phase one of the project was devoted to understanding and engaging the duals population via telephonic and print outreach, then developing a care management model reflecting both Triple Aim and patient-centered medical home goals. (The 23-site multi-specialty physician organization in Southern California has earned Joint Commission primary care medical home designation.)

At the heart of the model is a multidisciplinary care team, which counts a care coordinator, clinic patient navigator and care transitions coach among its eleven roles. Patients are stratified as high, moderate or low risk and matched to risk-appropriate interventions.

"Each member is activated based on where the patient is at in the continuum of care," noted Ms. Coles, who also reviewed team member roles and responsibilities and a host of complementary programs supporting care coordination during the May 2015 program sponsored by the Healthcare Intelligence Network.

In phase two, focused on development of end-to-end workflows, staff assessments and ratios, and team training, AltaMed hired an educator, fleshed out the patient navigator role, and examined integration of behavioral health and long-term services and supports (LTSS).

Phase three triggered a deeper dive into case manager caseloads and utilization patterns as well as several quality improvement activities.

Now in phase four, the goal of AltaMed's care coordination model is to ensure it can reflect a financial impact. "We'll look very closely at our per member per month cost and our inpatient metrics," Ms. Coles concluded.

3 Emergency Department Interventions to Curb ‘Ultra-Utilizer’ Use

March 31st, 2015 by Patricia Donovan

Drawing upon an 18-month pilot to curtail wasteful utilization in Ohio ERs, especially by Medicaid beneficiaries identified as 'ultra-utilizers,' Mina Chang, Ph.D., chief, health services research and program development section of the Bureau of Health Services Research for the Ohio Department of Job & Family Services, looks at three ED-based interventions targeting this population.

The ED care team approach is very similar for the three targeted ultra-utilizer groups: severe mental illness, non-mental health conditions, and chronic back pain. It’s based on a strong medical and clinical leadership oversight. The integrated interdisciplinary teams include managed care and community providers, and care management or care managers. They came together based on the patients’ medical profiles, developing an individual care treatment plan for each of the patients including the testing. The team would continue to outreach to those patients, to address their social and medical needs and to coordinate care for those patients.

The treatment plan at the summary level was made available to older participating EDs in the past intervention. The patient will be also flagged at those EDs. And the intent is if the member showed up at the ED, the ED attending physician would be able to reference on the treatment plan and also communicate with the interdisciplinary teams as necessary.

For the mental health stream, the designated provider is a comprehensive mental health center that works together with the managed care claims to develop treatment plans. And the summary level of the treatment plan will be shared with the participating EDs from the two health systems.

For these streams we also have a 24/7 crisis center so the EDs can tap into them to have the most updated treatment plan faxed over as needed.

We also have another integrated care team for the non-mental health population led by Metro Health’s medical home team. These designated providers work with our managed care plans to develop a treatment plan for each participating patient and the summary will be shared with the participating ED from the three health systems.

Finally, similar of design was a back pain stream with a pain clinic as the designated provider. This designated team works with our managed care plan care managers. In turn, they built a care treatment plan for those participating patients, and shared the treatment plan summary with the participating ED and the three health systems.

We already have very encouraging results. Almost all members reported their outreach from the team has been excellent or good. And that’s after we instituted the intervention. The majority of the members reported they have input into treatment plans, so most of them slowly follow up with their providers.

The unique area noted by the mental health team is that transportation, fear and timely appointments are the most common barriers preventing ultra-utilizer patients from seeking follow-up care after ED visits.

We also observed increasing success for members keeping appointments. Our teams also noted that communication is key, not only between the participating test site, since there are so many moving parts, but also within the test site, such as the pain clinics or the emergency department.

Source: 5 Interventions to Reduce Avoidable ER Use by the Medicaid Population

Reducing Avoidable ER Use

5 Interventions to Reduce Avoidable ER Use by the Medicaid Population looks at the collaborative effort among five Ohio regions to target key reasons for avoidable ER visits among Medicaid beneficiaries and roll out test interventions in a rapid cycle quality improvement approach.

10 Healthcare Trends Measured in 2014: Medical Neighborhoods, Data Analytics Flourish

January 13th, 2015 by Patricia Donovan

2014's HINtelligence Reports captured trends in healthcare delivery, technology and utilization management.


Each year, the Healthcare Intelligence Network's series of HINtelligence Reports pinpoint trends shaping the industry, from cutting-edge care collaborations to remote patient management connections to tactics to reduce avoidable utilization.

HINtelligence Report benchmarks are derived from data provided by more than one thousand healthcare companies.

Here are 10 highlights from 2014 HINtelligence Reports that support Triple Aim goals of improving population health and the patient experience while reducing the per capita cost of healthcare.

Share your reactions with us on Twitter @H_I_N.

  • Readmissions: More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, said respondents to the fourth annual Reducing Hospital Readmissions Survey.
  • Palliative Care: While the majority of respondents (68 percent) administer palliative care on an inpatient basis, more than half (54 percent) say care is conducted on home visits and just under a third offer palliative care at extended care facilities.
  • Patient-Centered Medical Home: Prepared to take their medical homes to the next level of care in the year to come, almost half—48 percent—have joined or expect to join a medical home neighborhood, defined by TransformMed℠ as “a strong foundation of transformed primary care practices aligned with health systems and specialists to insure that care is maximally coordinated and managed.
  • Remote Patient Monitoring: More than half of 2014 respondents—54 percent—have instituted remote monitoring programs, the survey found, which was most often employed for patients or health plan members with multiple chronic conditions (83 percent). Other targets of a remote monitoring strategy included frequent utilizers of hospitals and ERs (62 percent) and the recently discharged (52 percent).
  • Telephonic Case Management: More than 84 percent of respondents utilize telephonic case managers. „One-fifth of telephonic case managers work within the office of a primary care practice.
  • Population Health Management: The last two years reflects a dramatic surge in the use of data analytics tools barely on population health management's radar in 2012: the use of health risk assessments (HRAs), registries and biometric screenings more than tripled in the last 24 months, while electronic health record (EHR) applications for population health increased five-fold for the same period.
  • Emergency Room Utilization: Among populations generating the majority of avoidable ED visits, dual eligibles jumped nearly 10 percent in the last four years, from 2 to 11 percent, while other populations—high utilizers, Medicare and Medicaid—remained roughly the same. „„Chronic disease replaced pain management as the most frequently presented problem in the ER, at 54 percent.
  • Stratification of High-Risk, High-Cost Patients: The „LACE readmission risk tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Embedded Case Management: Fifty-seven percent of respondents embed or co-locate case managers in primary care practices, where their chief duties are care and transition management, reducing hospital readmissions and patient education and coaching.
  • 2015 Healthcare Forecast: Almost 92 percent of 2015 respondents said the impact of value-based healthcare on their business has been positive, with more than one quarter identifying healthcare’s value-based shift as the trend most likely to impact them in the year to come.

Make your healthcare voice count in 2015 by answering 10 Questions on Chronic Care Management by January 31, 2015. You'll receive a complimentary HINtelligence Report summarizing survey results.

Infographic: The Challenge of Serving Dual Eligibles

December 24th, 2014 by Melanie Matthews

Individuals dually eligible for Medicare and Medicaid are among the sickest and poorest individuals covered by healthcare in the United States. They are also likely to have mental health needs and live in nursing homes.

A new infographic by HealthX examines dual eligible healthcare spending, the challenges of serving dual eligibles and strategies for best serving this market.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population To locate, stratify and engage dual eligibles, Health Care Services Corporation (HCSC) takes a creative approach, employing everything from home visits to 'street case management' to coordinate care for Medicare-Medicaid beneficiaries.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population describes HCSC's innovative tactics to engage this largely older adult and disabled population in population health management with support from a range of community partners and services.

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Community Linkages Support HCSC’s Holistic Approach to Duals

September 25th, 2014 by Cheryl Miller

Meeting the holistic needs of the individual, and not treating them as a diagnosis has been key to Health Care Services Corporation's (HCSC) work with dual eligibles. Here, Julie Faulhaber, HCSC’s vice president of enterprise Medicaid, describes the organization's innovative use of community care connections to engage the unique challenges of this largely older adult and disabled population in population health management.

Question: What are some examples of HCSC community connections and how do these linkages benefit Medicare-Medicaid beneficiaries?

Julie Faulhaber: Our community connections are really critical to the success of our program. We work with a number of different community agencies in our state: the community mental health centers, the public health agency, and also with those types of agencies that deliver long term care services or have worked with those with mental health concerns.

We work across the board. All of these agencies catch our members, and we try to have relationships with them in order to gain access to our members, for example to better understand the types of services and support that our members truly need and where to access them. That’s been a key component of our program. We also look for community health workers who have backgrounds in the cultural needs of our members, which helps to engage them initially and maintain engagement.

HIN: What are the most common behavioral health issues your duals face and how has HCSC addressed these issues?

Julie Faulhaber: Our members have the full range of behavioral health issues that one would expect in a dual eligible population. Of course, the majority of individuals are experiencing depression and those types of concerns are often in conjunction with some physical disability. Referring back to the previous question on community linkages, we develop relationships with community agencies that support people with mental illness.

Other behavioral health concerns include those agencies that help people with recovery from addiction. We also worked with an integrated team in our own model of people with behavioral health backgrounds as well as our traditional physical healthcare model. That integration has been important for us in meeting the holistic needs of the individual and not treating them as a diagnosis.

dual eligibles care
Julie Faulhaber, vice president, enterprise Medicaid for Health Care Service Corporation (HCSC), a $52 billion health insurance company with 13.2 million members operating in five states, is responsible for the leadership and oversight of HCSC’s Enterprise Medicaid Business. This includes expansion of Medicaid programs across HCSC’s Blue Cross Blue Shield plans in Illinois, Montana, New Mexico and Texas.

Source: Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population

5 Models for Engaging Community Partners in Dual Eligibles Care Coordination

July 22nd, 2014 by Patricia Donovan

Since healthcare is local, it's vital that health systems engage local providers, enlisting both clinical and administrative champions, advises Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation. Ms. Faulhaber offers a variety of guidelines for engagement of community partners in care coordination for Medicare and Medicaid beneficiaries.

Our community care coordination partners may employ different models of care coordination. First, some may have care systems, larger accountable care organization (ACO)-type organizations; many take full financial risk, including risk on home- and community-based services. There are also waivers.

Second, some of these large care systems also have nurse practitioner (NP) models that provide mainly facility-based care. Those can be extremely successful with outcomes for the numbers, as well as from a cost perspective. Third, we also work with care management organizations and providers. Another example would be the Triple A’s—Adult Areas Agencies on Aging—and other behavioral health organizations. In our experience, these organizations will take on some financial risk, but really for those care coordination services.

Fourth, there are many different financial models you can use with both groups, particularly for the care management organization providers. For example, looking at a risk on care coordination, gain sharing—potentially in a new program—helping to pay for some startup infrastructure cost, providing loans with some paybacks. There are many different opportunities to make it financially viable for those important community partners to work with health plans in order to provide community-based, social model services to the member to meet all of their needs.

Finally, when working with community partners, it is critical to have both a clinical and administrative champion for the program. Clinically, it helps to have a physician nurse who can talk with their peers in the organization to help them understand the program. Clinicians want to provide care in a very uniform way, but if there is an opportunity to provide additional benefits in lieu of services for members, it helps to have that clinician champion to be able to share that.

Administratively, it is also important to manage the enrollment and care coordination paperwork. The plans are putting significant faith in these organizations to meet their contractual obligations, so having someone to follow up for those types of things is critical. It is also important to provide reporting and feedback on the results for these groups. We have done quarterly meetings in the past, which I found to be very helpful.

It is also helpful to provide benchmarking data. We look at how one organization serving the same population in a similar environment shapes up in comparison to another. This has improved results overall; it makes those organizations leading the pack feel good, and provides those trying to catch up with some role models to look at.

Excerpted from: Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population

5 Ways to Reach, Engage Dual Eligibles

May 15th, 2014 by Cheryl Miller

It takes a village — and more — to locate, stratify and engage dual eligibles, says Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC), especially when they can range from school-aged children to elderly Native Americans. Here, she discusses how to best engage the company's diverse population.

Here’s an example of a Centennial Care outreach plan, which includes our dual eligibles. It has our Medicaid adults and children. There are not very many school-based children that are dual eligibles, but there are some, so working with the school-based clinics, the nurses’ association, etc., helps us engage.

In the New Mexico market, working with the Native American community is very important in engagement and sometimes actually for locating our members. Working with the tribal government and their leadership, some of the urban health centers, Indian health organizations, and other community organizations under the Native American groups can be extremely helpful. And some of our populations work with our behavioral health groups so again, those community mental health centers and other community organizations serving those with mental health and behavioral health concerns are of value to us.

We also work with community and public health outreach in this market. Promotoras or community health workers are critical elements for us to not only engage, but then also to maintain our relationship with members. With some of these outside agencies, we often have contractual relationships, and are able to share personal health information back and forth. That makes it much easier for us to locate members, and also have some of the staff in these organizations be part of our interdisciplinary care team.

Excerpted from Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population.

3 Components of Geriatric Health Management for Dual Eligibles

March 27th, 2014 by Cheryl Miller

When designing care management programs for dual eligibles, you need to recognize the strong connection between the medical, the social and the behavioral, explains Timothy C. Schwab, MD, FACP, former chief medical officer of SCAN Health Plan. Ultimately, you are caring for the individual; one person in charge of the whole program.

I’d like to give a broad overview of the care management model that we’ve been using at SCAN. It begins with assessment care planning and care management. But we see it as a continuum — a cross between very traditional medical care management and traditional social care management. We’ve combined it into a centralized spot we call our ‘geriatric health management program.’

We meld all that into one care management program — the medical, the social, the behavioral. And then we utilize expertise from the medical sides; for instance, for a patient with diabetes, we use our diabetic disease management module by that geriatric care manager. Or for behavioral health issues, we use the behavioral health side of the program. But again, it all focuses on the individual; one person in charge of the whole program.

When you design for the dual eligible population, you can divide the population into those that are frail and disabled as a primary type of program, but also recognize that this is a low income population with multiple complex chronic conditions. Coordination is the critical link between the social and the medical. Incorporating the traditional things like disease management, utilization management, transition management and complex care management is essential, since all of these are very critical and interrelated.

Excerpted from Community Care Connections for Dual Eligibles: Closing Social Gaps to Improve Health Outcomes.

5 Community Partners Supporting HCSC Dual Eligibles Care Coordination

March 19th, 2014 by Patricia Donovan


From 'street case managers' that help locate and engage the homeless to tribal leaders who are liaisons to the Native American population, Health Care Service Corporation (HCSC) has assembled a dream team of community partners to support care coordination of dual eligibles.

Community mental health centers, public health agencies and community agencies round out the cadre of care coordination supports for Medicare-Medicaid beneficiaries, explained Julie Faulhaber, HCSC's vice president of enterprise Medicaid during a recent webinar on Moving Beyond the Medical Care Coordination Model for Dual Eligibles.

This safety net for dual eligibles is a hallmark of three duals care coordination models launched by HCSC in 2014—two in New Mexico and one in Illinois. Results from a home-grown health risk assessment, or HRA, (conducted telephonically in almost all cases) enables HCSC to risk-stratify duals and refer them to appropriate care teams.

Other care coordination elements include interdisciplinary teams, a whole-person rather than diagnosis-driven focus and novel care and services planning that encourages out-of-the box thinking—like the installation of a grab bar in the home of a senior somewhat unsteady on her feet.

"Putting in a grab bar might cost $150 to $200, but when you think about that in terms of having that member have a fall and having them hospitalized and the rehab cost, it just makes sense for the member's quality of life and comfort to know that there is something there to help them," noted Ms. Faulhaber.

HCSC takes great care to consider the needs of individuals with disabilities as well as those with behavioral health concerns, Ms. Faulhaber stressed, citing a 2006 study that found that individuals with severe mental health issues die 25 years earlier than those without.

While HCSC's duals care coordination interventions are new, Ms. Faulhaber believes efforts will pay off for the organization's Medicare-Medicaid members. In her more than 10 years experience with Medica Health Plans in Minnesota, where she was responsible for the dual eligible product suite, duals care coordination significantly enhanced quality and utilization metrics for that population.

Despite the efforts of HCSC and other payors to enhance duals' care coordination, significant roadblocks remain, such as transportation, a lack of integrated care, and the population's typical low scoring in risk adjustment, a common trend in groups with primary behavioral conditions, she explained.

Listen to an interview with Julie Faulhaber of Health Care Service Corporation here.

Readers, how are you rising to the challenge of duals care coordination? Are your case managers 'on the street' like HCSC's, or do you have other ways of identifying and assisting the dually eligible with their physical and behavioral health needs? Share your ideas with this community.

5 Considerations for Developing a Dual Eligibles Program

February 5th, 2014 by Jessica Fornarotto

Congress has responded to the differences and unique needs of the dual population, states Dr. Timothy Schwab, former CMO of SCAN Health Plan, creating the Office of the Duals and the Innovation Center.

Dr. Schwab stresses the importance of defining the goals and the population when developing or participating in a dual eligible program.

If you're developing or participating, you need to define your goals, which will ultimately lead to how you develop the care management program and the metrics. Everything relates back to the Triple Aim of better health, better care and better cost.

It's important to get as much information about the population you're going to serve as possible. You need to look at the age bands, which is relatively easy for most states. You need to also look at how many people are in each age band, and what the program is going to serve.

Third, it's important to understand the functional status of this population. This may be a little bit harder to get from the state because they probably only have information available for the population currently being served by the long-term supports and services programs in the community. And we know that there are people who aren't being served that the state is not aware of.

When it comes to the medical status, the state has very little information on this because Medicare is the primary payor and the state only secondarily gets any information on medical status.

Fifth, the social status is also critical: Where do they live? What is their caregiver status? What percent of them have caregivers? What percent live in their own home? Then, you must consider issues such as language, literacy, and culture: What percent of them are non-English speaking? What cultural improvements must you consider when serving certain parts of the population?

Excerpted from: Population Health Management for Dual Eligibles: Blueprint for Care Coordination