The nearly 12 million Americans who are dually eligible for Medicare and Medicaid are among the nation’s highest-need and highest-cost populations. Integrated health plans, which combine physical and behavioral health care and long-term services and supports, offer a promising opportunity to improve care for this vulnerable population as well as control costs. Between 2011 and 2018, the number of dually eligible individuals enrolled in integrated plans grew from approximately 162,000 to nearly 800,000.
Enhancing Integrated Health Plan Services through Community Partnerships
Leading integrated health plans are reaching beyond their walls and working closely with delivery system partners to implement promising practices that achieve mutual goals in improving care and outcomes for their members. Ultimately, these partnerships combine plan and provider resources, energy, and expertise to accelerate adoption and spread of improved complex care management, member engagement, and value-based arrangements.
PRIDE Plan Project Profiles
This series of profiles outlines how innovative integrated health plan-delivery system partnerships are piloting new strategies to improve care for dual eligible.
- Improving behavioral health care management for high-need individuals;
- Reducing preventable admissions and improving care transitions from inpatient care to home and community settings; and
- Advancing patient and provider engagement in primary care settings.
Following are examples of how PRIDE plans are partnering to address each of these key areas:
1. Improving Behavioral Health Care Management
Individuals with behavioral health needs, including those with serious mental illness (SMI) and substance use disorders (SUD), often have high rates of acute care utilization. By forging innovative partnerships with a range of behavioral health providers, integrated health plans can seek to divert members with complex behavioral health needs from emergency departments toward community-based providers. Following are examples of PRIDE plan efforts underway (see also profiles of plan activities):
- CareOregon is working with a health system to embed health resilience specialists in psychiatric inpatient and emergency services units, with the goals of reducing length of stay and readmissions by coordinating care and rapidly connecting members to community-based services. These specialists will work with members following discharge to help them access care and navigate community systems.
- Health Plan of San Mateo is partnering with a county-based specialty care system for mental health and SUD to strengthen linkages between medical, behavioral, and social services and improve services for members with behavioral health needs. The partnership will focus on improving care coordination and administrative capabilities, as well as identifying community-based options for members discharged from inpatient psychiatric units.
- UCare is developing a withdrawal management service model for members with SUD in partnership with a county human services agency. This model will reduce fragmentation of SUD services by treating members in need of detoxification in the most appropriate setting. It aims to reduce the use of acute care services for SUD needs and increase the percentage of members with SUD who complete withdrawal management services.
- UPMC for Life Dual is partnering with a behavioral health organization to implement an evidence-based behavioral health home model for members with SMI and complex physical and behavioral health needs. This model embeds care managers at community mental health centers to optimize health outcomes for individuals with SMI while increasing patient engagement and reducing readmissions.
2. Reducing Preventable Admissions and Improving Care Transitions
Restructuring care management practices can reduce unnecessary admissions to inpatient settings and increase members’ ability to remain in home and community settings. Additionally, a value-based payment (VBP) approach with home health care providers may improve the quality of care during and after these transitions. The below PRIDE plan examples are assessing the efficacy of these approaches:
- CareSource is partnering with hospital systems and Area Agencies on Aging on a multi-phase care management model to identify and support members able to transition from nursing facilities to community settings. Activities include: delegating care management staff to these efforts; enhancing coordination channels between post-acute care staff and care managers; and, eventually, executing performance-based contracts with community-based organizations to support these transitions.
- iCare is partnering with a large delivery system to develop a follow-to-home care management program for individuals at high risk for readmission. This initiative includes: a predictive modeling tool to assess readmission risk; an assigned care manager who serves as the “eyes and ears at home;” and financial incentives for home health agencies that deliver high-quality care.
- VNSNY CHOICE is working with a licensed home care service agency to reduce potentially avoidable hospitalizations. CHOICE developed a VBP model to reward its partner for improving specific member outcomes, and will provide ongoing supports through real-time data exchange and workforce development efforts.
3. Advancing Patient and Provider Engagement in Primary Care
Integrated health plans that work closely with primary care providers to engage, educate, and activate members may achieve better health outcomes. Additionally, increasing provider care coordination capabilities may be particularly beneficial to vulnerable populations. The following PRIDE plans are examples of how these efforts may be implemented:
- BlueCare Plus is partnering with a large primary care practice to create a care coordination platform and a flexible provider and member engagement strategy to improve outcomes related to primary care visits and inpatient admissions. BlueCare Plus is developing streamlined policies and procedures to increase collaboration among physician groups in its network serving high-need members.
- Commonwealth Care Alliance will support selected primary care providers in designing quality improvement projects to advance consumer-centered care for members with complex needs. Efforts will focus on: (1) individuals with physical disabilities, mental illness, or those who face social isolation; or (2) projects that otherwise address one or more social determinants of health. Patients from those practices will participate in the design and implementation of projects to eliminate key barriers to achieving optimal care, health, and function.
Learning from Health Plan-Delivery System Partnerships
As PRIDE plans implement these projects, CHCS is helping them measure and achieve progress toward their designated goals. Promising practices and key lessons from this work can inform other health plan and provider efforts to build better models of care for dually eligible beneficiaries. In addition to disseminating experiences from these new partnerships in future CHCS communications, many of these projects will also contribute to the Better Care Playbook, a foundation-supported resource that provides actionable steps for health care organizations to improve the delivery of care for people with complex needs.