Posts Tagged ‘dual eligible’

Infographic: Advancing Medicare and Medicaid Integration

December 18th, 2017 by Melanie Matthews

There are more than 11 million individuals who receive services from both Medicare and Medicaid. State policymakers and their federal and health plan partners are increasingly seeking opportunities to improve Medicare-Medicaid integration for these dually eligible beneficiaries, according to a new infographic by the Center for Health Care Strategies.

The infographic explores the reasons to integrate care for dually-eligible individuals; features of effective programs; and factors influencing state investment in integrated care.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid PopulationTo 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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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.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

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.

Infographic: Home Health Patients Versus All Medicare Beneficiaries

August 15th, 2013 by Jackie Lyons

In recent years, the home health benefit has been hit with spending cuts, which have the potential to directly impact the services offered to vulnerable Medicare recipients.

Seventy-eight percent of Medicare’s Home Healthcare Patients are non dual-eligible patients and are not covered by Medigap insurance, according to a new infographic from the Partnership for Quality Home Healthcare. This infographic explains the differences between Medicare home health beneficiaries and the average Medicare beneficiary, as well as the most chronic conditions treated by home health.

Home Health Patients Versus All Medicare Beneficiaries

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You may also be interested in this related resource: Population Health Management for Dual Eligibles: Blueprint for Care Coordination.

5 Tips for Seniors to Avoid Hospital Readmissions

June 24th, 2013 by Jessica Fornarotto


Nearly one in five seniors who are hospitalized return to the hospital within 30 days, according to a recent Robert Wood Johnson Foundation report. These readmissions are not only often physically and mentally debilitating to the seniors and their families, but contribute greatly to avoidable and unnecessary expenses on the nation’s healthcare system. To help curb these numbers, SCAN Health Plan recently offered seniors five strategies to lessen the chance of readmission.

  1. Ask questions before discharge. When patients are in the hospital, they’re completely dependent on others for care. But once they’re home, they’re in charge of their own recovery, which makes understanding what to do the key. Patients being discharged from the hospital who ask questions and who have a clear understanding of their after-hospital care instruction are 30 percent less likely to be readmitted or to visit the ED than patients who lack this information, according to a recent study from the AHRQ.
  2. Understand medications. This is particularly important if there have been changes to a medication regimen while in the hospital. Upon discharge, dosages are sometimes changed or a drug is discontinued or added. Patients need to be sure about this and to write it down. They also need to be sure to fill all new prescriptions once they’re home.
  3. Make a plan for follow-up care. Patients need to know when to schedule a follow-up visit to their doctor, and to make sure that they have the transportation to get there. Even if they’re feeling good, they should go anyway. The doctor needs to see a patient in order to track how they’re doing and to gauge whether the treatment plan is working. In addition to doctors, does the patient need to schedule home healthcare with a nurse or therapist, or do they have some new durable medical equipment or home-modification needs?
  4. Communicate with care coordinators. Whether a patient has a professional in-home caregiver, a family member nearby, or resides in an assisted-living community, they need to make sure that their caregiver is up to date on the recent hospitalization and how the patient is feeling. This also goes for the patient communicating with their health plan, as many have programs and professionals in place that can assist with care coordination.
  5. Be aware of “red flags” or complications that should be reported. What is considered “normal” for a patient’s post-hospital condition? What degree of pain or swelling is expected? Patients need to know what to look for, whom to call if they are not feeling well, and to have a clear plan of action in place so they know how to respond to a complication.

Romilla Batra, M.D., vice president and medical director of SCAN, says that readmission rates for seniors can also be reduced by enrolling in a health plan that has a strong emphasis on integrated care and care management. She points to a 2012 study released by Avalere Health that compared 30-day all-cause hospital readmission rates between California dual-eligible (Medicare and Medi-Cal) individuals in traditional Medicare versus those enrolled in SCAN Health Plan. The independent study found that SCAN’s dual-eligible members had a hospital readmission rate that was 25 percent lower than those in fee-for-service.

“Industry-wide efforts are underway to bring down readmission rates including new rules passed as part of the Affordable Care Act that charge additional fees to hospitals with excessive readmissions,” said Dr. Batra. “But ultimately it is still the consumer themselves who can play the biggest role through common sense and following these five easy steps.”

Risk Assessment, Case Management Help to Improve Dual Eligibles’ Health

April 30th, 2013 by Jessica Fornarotto

“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.