Archive for the ‘Dual Eligibles’ Category

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

Community ‘Feet on the Street,’ HRAs Improve Dual Eligibles’ Health

January 14th, 2014 by Jessica Fornarotto

A local approach — the integration of public health with managed care — is what a lot of states and CMS are starting to look for, explains Pamme Taylor, vice president of advocacy and community-based programs for WellCare Health Plans.

In HIN’s special report, Community Care Connections for Dual Eligibles: Closing Social Gaps to Improve Health Outcomes, Taylor describes some of WellCare’s efforts to connect its dually eligible population to health services, including making contact, identifying services for each member and assessing health status via health risk assessments (HRAs) that are part of these community services.

Question: What is WellCare’s strategy and practice for contacting dual eligible members and ensuring follow-through with recommended referrals to community support services?

Response: This question is two-fold; first, how do we reach the members and get them engaged? And second, how do we verify that services were rendered? For members, we have street teams that go out into the community investments. We also have community health workers on our interdisciplinary team. It’s their job to connect with our members on a face-to-face basis while also connecting them to community supports. It’s through that model that we heavily rely on engagement and connectivity, etc.

Our first line of outreach is through the phone; our second line is through the community health workers and the individuals that are ‘feet on the street.’ And then, how do we verify that services were rendered, and how is that data collected? We have a command center, which is the warehouse of all that information, and then the social service electronic health record (EHR), which bolts onto the member’s medical record. That process produces a provider roster that we then put into the hands of our field teams, who use that as part of relationship management, much like a provider relations representative would use in their engagement with the primary care physician (PCP). We meet with them on a regular basis to confirm that services were rendered, and review the successes.

The secondary piece to that is our case managers also reach out to the members that they have referred to services and activities. They verify through the members they received it and their level of satisfaction. So there’s two points of feedback: one from the provider themselves and one from the member.

Question: How do you identify community services to meet members’ needs?

Response: It’s similar to the United Way 2-1-1 directory. We did community health needs assessments, which identified a number of different needs. And using epidemiological information, we come at it in terms of identifying the need, and then determining the service model. Then we took it a step further and asked, ‘How do we define the services so it’s a blend between public health, social supports and managed care terminology?’

We use about 67 different categories of social supports. We turn that into research. We go ‘feet on the street’ to canvas the neighborhoods to make sure that we have all of the organizations represented. Then that’s put into a ‘pend’ status in our databases and it is vetted on a secondary level of review by our team of liaisons. Once it’s vetted and confirmed, it’s then put into the final database, which is used for searching by our case managers. It’s a combination of public health practice using both public health and managed care terminology.

There is no magic number of categories or organizations. No one’s ever systematically inventoried or catalogued the network of social services. That’s what we’re hoping to do — explain and quantify what organizations exist, then identify their service area, their reach, their service portfolio, and the volume of connectivity that the health plans have with these organizations for specific services. It’s an exciting time.

Question: What other components of the comprehensive health assessment are administered to the duals as they come on board?

Response: A number of different factors go into the HRA that’s completed. There are health factors, socioeconomic factors, living environment, and activities of daily living (ADL). What are their social needs, what are their social supports, etc.? There’s a whole number of different tiers of questions that we ask as part of the HRA. We use very specific tools that are either state-dictated or guidelines produced by the state or in partnership with CMS. It depends on which side of the equation that we’re being contracted for, and it depends on what’s already in existence.

HINfographic: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

December 23rd, 2013 by Jackie Lyons

With time and resources at a premium, healthcare organizations are increasingly selective about allocation of human and financial capital. There are, however, a select group of initiatives and strategies worthy of C-suite investment.

Population health management, care coordination and integrated care delivery are among the top patient-centered healthcare strategies in 2014, according to a new infographic from the Healthcare Intelligence Network. This HINfographic also identifies the other top strategies, as well as metrics from existing programs.

7 Patient-Centered Strategies to Generate Value-Based Reimbursement

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Information presented in this infographic was excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement. If you would like to learn more about patient-centered strategies for value-based reimbursement, this resource includes even more information, including hospital-SNF care transitions, closing dual eligible care gaps, and lessons learned and results from some of the most recognizable names in healthcare — Kaiser Permanente, Mayo Clinic Health System, Monarch HealthCare, HealthFitness, and WellCare.

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

Healthcare Business Week in Review: Oncology PCMH; Medication Management; Seniors on FB

November 29th, 2013 by Cheryl Miller

As families gathered this week to celebrate Thanksgivikkuh, (which won’t happen again for 77,000 years!) we offered several stories that demonstrate the strength of partnerships.

To begin, a first-of-its-kind patient-centered medical home (PCMH) model for oncology from Aetna and Consultants in Medical Oncology and Hematology, PC (CMOH).

The collaboration combines evidence-based decision support in cancer care with enhanced personalized services and realigned payment structure and is designed to increase treatment coordination and improve quality outcomes and costs for cancer patients. Researchers found that more than half of all new cancer patients are 65 or older, and most have one or more health conditions in addition to cancer. Given their frequency of contact with patients, oncologists are well positioned to help their patients coordinate care for multiple conditions.

Physician-led, team-based models of care are the future of healthcare, according to the AMA, which has issued a set of recommendations for implementing these models, including a report for the development of payment mechanisms that promote satisfaction and sustainability of team-based models in various practice settings. Among the recommendations: establishing payment distribution models that foster physician-led team based care, and reimbursing those physicians who lead these teams accordingly.

High-risk heart failure patients receiving nursing interventions were four times as likely to take their medication, but their hospital readmission rates were not impacted, according to a new study at Duke Medicine.

Patients who were tutored about managing their symptoms, taking their pills on schedule, and developing an action plan for addressing their symptoms were more likely to take their prescribed medications. They were encouraged to use doctors’ offices and clinics rather than the emergency department.

But when the researchers looked at the hospital readmission rate, they found that readmissions were not significantly different between the two groups. Medication management is just one of many issues facing patients most at risk for their conditions to worsen, researchers found, and redesigning care to confront the issues that are keeping the vulnerable from regaining their health has to be addressed.

Developing a communication hub, virtually and in person, is critical to a successful care coordination plan for dual eligibles, says Timothy C. Schwab, MD, FACP, former chief medical officer of SCAN Health Plan. It ensures that all members of the immediate and long-term support team are in sync with each other.

Seniors want to stay connected. According to a new Accenture survey, more than half of seniors 65 years and older are seeking digital options for managing their health services remotely. In fact, researchers found that at least three-fourths of Medicare recipients access the Internet at least once a day for e-mail (91 percent) or to conduct online searches (73 percent) and a third access social media sites, such as Facebook, at least once a week.

And lastly, a way for you to communicate with us: participate in our fourth comprehensive online survey, Reducing Hospital Readmissions Benchmark Survey, and we will send you a free e-summary of the results once they are compiled.

ABC’s of Healthcare 2014: Accountability, Bundled Payments and Consolidation

November 6th, 2013 by Patricia Donovan

Webinar Replay: 2014 Healthcare Trends & Forecasts, A Strategic Planning Session

“Use performance metrics and hold people accountable to the metrics. The days of all the excuses have really come to an end.”

Rationalizations for the poorly performing ObamaCare Web site aside, Steven Valentine’s advice during HIN’s tenth annual Healthcare Trends & Forecasts program underscores the accountability factor in value-based healthcare.

There really aren’t any more excuses for poor clinical outcomes or wasteful spending — not with the proliferation of evidence-based, patient-centered care models and tools to track population health.

Accountability is part of the Triple Aim mentality that pervades the industry and colored predictions by both Valentine, president of The Camden Group, and Catherine Sreckovich, managing director in the healthcare practice at Navigant, during HIN’s tenth annual Healthcare Trends & Forecasts in 2014 Strategic Planning Session. Prognostications by these industry thought leaders on the care delivery and reimbursement strategies to watch in the year ahead bolster the notion that big data, risk-stratified accountable care and performance-based reimbursement are here to stay.

Although healthcare will continue to live in a fee-for-service world for a while longer, acquisition and consolidation by physicians and hospitals will continue, and integrated delivery networks powered by bundled payments are healthcare’s best bet for value and integration, Valentine said. It’s one reason he’s “bullish on medical homes: they can be effective and have in many cases been able to reduce hospital admissions by 5 to 7 percent.”

Accountability also extends to new models of care delivery — the medical neighborhood, an amped-up version of the patient-centered medical home that pulls specialists, care coordinators and community linkages into the care continuum, or the “Team Approach, One Member at a Time” population health management philosophy of Kaiser Permanente, which Valentine hailed as “the poster child for the Obama administration as to what an ACO might look like.”

Dual eligibles, whose care is often fragmented, present an opportunity to benefit for monies available for Medicare-Medicaid beneficiaries. However, Valentine urges caution in the duals arena. “Dual-eligibles are extremely difficult to manage, they are non-compliant patients. Unless you manage care really well, being in a dual-eligible managed care system will probably cost you money.”

The accountable care organization continues to hold promise, he said, but despite the proliferation of ACOs, not all have delivered as expected. He advises ACOs to shore up infrastructure and focus more on medical management.

Ms. Sreckovich, parsing the healthcare year ahead for payors, concurs with Valentine on the potential of the ACO, but also cautioned that as with other shared savings models (bundled payments and patient-centered medical homes, for example) there are hurdles to ACO implementation that remain, including their high setup cost. “Organizations have to have the right resources, staff, time, money, etc., to meet their accountability targets,” she said.

On recommended reimbursement models for ACOs, Ms. Sreckovich was partial to bundled payments, shared risk, and incentives tied to value and wellness outcomes. “Those are the payment models that health plans are starting to emphasize as they’re negotiating terms of new arrangements.”

in her payor-focused comments, Ms. Sreckovich pointed out the extreme variation in the number and types of available health plans at this time — a scenario complicated by the problematic rollout of the health insurance exchanges. It remains to be seen what impact the government’s technical difficulties will have on the industry, but as of right now, Ms. Sreckovich doesn’t expect the low tax penalties for the uninsured to be enough of a motivator for enrollment.

The recent ACA-related troubles may result in the creation of more private insurance exchanges such as the one Walgreen’s created earlier this year. The discount retailer is moving 120,000 employees to a private health insurance exchange from coverage provided directly from carriers.

For her part, Ms. Sreckovich is bullish on big data, but advised health plans “not to use data for data’s sake but instead use analytics to transform from ‘payor’ to ‘value generator.'” It is also critical to get more data into consumers’ hands, she stressed.

“So far, data for consumers has been relatively limited, which is a problem because we want consumers to make decisions based on cost and quality. So we really have to get the data to them.”

Listen to interviews with Mr. Valentine and Ms. Sreckovich.

Healthcare Business Week in Review: Childhood Obesity, Dual Eligibles, ACOs, Patient Activation Measures

November 1st, 2013 by Cheryl Miller

Last year at this time we watched with disbelief as Hurricane Sandy pummeled our East coastline. Schools closed, power shut down, and Halloween was officially postponed until early November when it was considered safe for children to trick or treat.

Our own town is still recovering from the storm; scarred, vacant houses share the same block as rehabbed homes on stilt-like platforms; trailers double for once elegant restaurants and broken docks and abandoned boats patiently ride the crests of ocean waves.

It was a rocky year for healthcare as well, from an early surge in Medicare ACOs, to the embattled introduction of ACA-mandated health insurance exchanges during a government shutdown.

But many things remained the same; childhood obesity rates continued to climb , as did public health efforts to control it, including counseling and nutritional guidance, according to a new trends report from NCQA. Poverty continued to plague many Americans, particularly dual eligibles, but companies like Wellcare did their best to help them by closing social gaps with health-oriented community connections looking to “give back,” as its vice president of advocacy and community-based programs executive director Pamme Taylor demonstrates in this week’s featured book excerpt.

Organizations like HealthEast and Mercy utilized clinical analytics technologies from Optum to better understand and manage treatment for patients with chronic conditions, and advance performance for its newly formed accountable care organization (ACO).

And doctors’ policies toward accepting new Medicaid patients in the wake of expanded coverage will most likely stay the same, according to a study from Virginia Commonwealth University, Richmond. The decade-plus study found that physicians might be more likely to stop accepting those patients who remain uninsured, however, as our story details.

And lastly, self-management continues to result in better patient outcomes, according to researchers from the Boston Medical Center. Patient activation, or having the knowledge, skills, and confidence needed to manage one’s health, leads to better health following hospital discharge, and lower readmission rates. Screening for patient activation could not only help hospitals identify patients at risk for readmission, but also inform the development of tailored, cost-effective intervention plans.

How did your healthcare organization fare in 2013? And what plans do you have the future? Tell us by completing our ninth annual survey on Healthcare Trends for 2014 and you’ll receive a free executive summary of the results. One respondent will win a training DVD of the “2014 Healthcare Trends and Forecasts” webinar recorded on October 30, 2013.

Healthcare Benchmarks Video: Coordination of Care for Dual Eligibles

October 30th, 2013 by Jackie Lyons

Care coordination of the 9 million Americans eligible for both Medicare and Medicaid is a growing priority for the nation’s payors who wish to address this population’s unique medical, social and functional needs in a coordinated and cost-efficient manner.

This video from the Healthcare Intelligence Network features exclusive, actionable data from HIN’s 2013 Coordination of Care of Dual Eligibles survey.

During the exclusive video, Timothy Schwab, former chief medical officer for SCAN Health Plan, discusses the SCAN Duals Care Team, which reflects the diverse needs and identities of dual eligibles. This video identifies the target population for programs and the key staff members needed to coordinate the care for these dual eligibles.

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

New Market Data: Physicians Ahead in Dual Eligibles Care Management

October 23rd, 2013 by Patricia Donovan

Health coaching, home visits, case management and transitional care are key components of care coordination for the dually eligible.

Physician practices are more advanced in care coordination of Medicare-Medicaid beneficiaries and much further along in duals program development than the industry as a whole, according to physician practices that responded to the 2013 Healthcare Intelligence Network Survey on Dual Eligibles Care Coordination.

Not only do nearly 86 percent of participating practices have a care coordination program tailored to dual eligibles (versus 54 percent of overall respondents), but fully 100 percent of remaining respondents in this sector say they’ll launch a duals-focused care effort in the coming year.

The physician practice sector, which comprised 17 percent of overall respondents, is more dedicated to disease management and transitional care, with 100 percent of responding practices offering these services in duals care coordination, versus 77 percent and 68 percent, respectively, in programs of overall respondents.

With physician practices so far ahead in this area, reporting significant impact and ROI from interventions aimed at Medicare-Medicaid beneficiaries, their approach merits a closer look. An examination of the data reveals that it’s not so much that the practices are doing things differently; certainly, the majority of respondents are using case management, educational tools and transitional care to improve population health in dually eligibles.

However, practices are doing a great deal more of everything — from being fully engaged in disease management and coordination of care transitions to employing health coaching and visiting patients at home. These strategies are translating into improved outcomes and less utilization on the part of these patients. And the physician is taking the lead on care coordination interventions.

A word about the home visits: in a concurrent survey on Home Visits, 75 percent of responding healthcare organizations say they visit their health plan members and patients in their home — mostly to check on these individuals following discharge from the hospital but also to perform home assessments. For the dually eligible, these assessments can be essential in uncovering some of the unique psychosocial issues these beneficiaries face.

“Critical to this population is the home component,” notes Dr. Timothy Schwab, the former chief medical officer of SCAN Health Plan and now president and CEO of Tim Schwab Healthcare Solutions, Inc. SCAN, a not-for-profit California-based health plan, has a history of successful care management of dual eligibles, having developed a multi-pronged, member-specific approach to reaching dual eligibles that has earned kudos from the healthcare industry.

“You must develop a model that includes what’s happening in the home,” continues Dr. Schwab, “Because the social and home environment impacts everything, including compliance with medications and the physician’s medical advice. It encompasses nutrition and transportation issues. If the person lives where they have no access to transportation, you’ll have to be able to provide that.”

The community connection is essential as well, contributes Pamme Taylor, WellCare’s vice president of advocacy and community-based programs. The philosophy that healthcare is local — and therefore, care needs to be local and community-based — forms the core of WellCare’s efforts to connect its dually eligible population to health services, Ms. Taylor explains. The Tampa-based healthcare company takes a culturally competent approach to assessing duals’ unique personal circumstances, insuring their “soft landing” into WellCare’s care coordination system.

Care managers at the heart of WellCare’s multidisciplinary team, conducting a comprehensive needs assessment with each Medicare-Medicaid beneficiary and driving the resulting care plan, ensure duals’ complex care needs are met at the most appropriate time and level.

Click here for an executive summary of the Dual Eligibles survey results.

HINfographic: Healthcare Strategic Planning for 2014

October 16th, 2013 by Jackie Lyons

Sustained growth in emerging reimbursement models, including accountable care, bundled payments and shared savings will continue to have an impact on innovation within the healthcare industry in 2014 as providers and payors struggle to find more ways to reduce costs within their systems and better manage the care they provide.

Hospital readmissions dropped by nearly 70,000 in 2012, and this trend is expected to accelerate through 2014, according to a new HINfographic from the Healthcare Intelligence Network. This HINfographic identifies current healthcare industry trends, and provides details on what to expect in 2014.


Healthcare Strategic Planning for 2014

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.

Information presented in this infographic was excerpted from: Healthcare Trends & Forecasts in 2014: A Strategic Planning Session. If you would like to learn more about healthcare trends and forecasts in 2014, this resource includes a detailed and actionable roadmap to the key issues, challenges and opportunities for healthcare providers and payors in 2014.

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