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Commonwealth Care Alliance:

Care for Medicaid and Dual Beneficiaries with Complex Care Needs Through Primary Care

“Health Home” Redesign

Robert J. Master, MD

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Case Vignette n  Anna C. is a 55-year-old woman, SSI eligible Medicaid beneficiary with long

standing Multiple Sclerosis with complete paralysis in both legs, partial paralysis in both arms and impaired bladder function. A long standing history of depression, a prior major suicide attempt and a history of severe asthma exacerbated by heavy smoking, predated her MS. For many years, Anna was able to use a manual wheelchair and perform self catheterizations but with slowly progressive upper extremity weakness this became impossible. Anna has received two hours of PCA care each morning and each evening for the past five years without adjustment despite functional decline. During the past two years there have been multiple hospitalizations for urinary tract infections, asthma exacerbations, and two long sub acute hospital stays for pressure sore management caused by extended hours in bed and a poorly fitted manual wheelchair. At the time of enrollment, Anna was found to have no consistent primary care or BH relationship and she was severely depressed, emotionally withdrawn, functionally bedbound, incontinent, and with rapidly worsening decubitus ulcers.

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Why Does Anna C’s Experience Cry Out for a “Health Home”

§  Anna is an example of Medicaid and/or Dual Eligible beneficiaries where care is totally inadequate and as a consequence unnecessarily costly.

§  Predictable and preventable secondary complications, such as, urinary tract infections, asthma exacerbations, pneumonias and decubitus ulcers drive recurrent hospital contacts, declining health, poor outcomes and most costs.

§  Primary care as resourced and organized in both FFS or MCO iterations is hopelessly ineffective. Payer based care coordination strategies are also hopelessly ineffective.

§  Needed LTC, DME and BH services are allocated (or not) without any kind of an individualized care plan, monitoring or sensitive modulation over time.

§  Continuity clinical management through all settings at all times, is non-existent.

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Commonwealth Care Alliance n  Non profit, fully prepaid care delivery, exclusively caring for Medicaid and

Dual eligible beneficiaries with complex care needs: n  3000 Dual/Medicaid eligible elders – 70% NHC. n  2700 younger Medicaid beneficiaries with multiple chronic medical and

BH conditions and/or disabilities. Via

n  25 primary care practices in Massachusetts low income communities with the following:

Primary Care Practice Redesign Elements n  Multidisciplinary clinical teams (RNP’s, RN’s BH clinicians, SW’s, CHW’s)

integrated into practices to enhance primary care and provide individuals care coordination ($200-$600 PMPM costs).

n  IT infrastructure from claims and clinical data to promote continuous care improvement.

n  24/7 RN/RNP call availability with EMR support. n  Continuity management/coordination in all settings at all times. n  New in hospital “nurse partners” to promote safe and effective discharges

and seamless continuity

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“Health Home” Redesign Element n  Comprehensive (often home based) multidisciplinary assessments, replace

typical physician “H+P”. n  Individualized care plans, resource allocations, monitoring and modulating by

the clinical teams for LTC, DME, BH services, replaces impersonal “rule based” benefits.

n  Clinical team empowerment to “order and authorize” all services, replaces inefficient supplications to a distant Medicaid or BH carve out bureaucracies for “approval”.

n  Elastic RNP home response capability, to assess and manage new problems, replaces the Ambulance and ED.

n  For those with physical disabilities– integrated DME clinical assessment and management, replaces distant PA processes and months of delay.

n  For those in need of BH service, integrated BH clinician assessment, individualized care plan development, implementation and management replaces inaccessible “vanilla BH carve out options”.

n  24/7 clinical availability and continuity management replaces “going it alone”. n  Web based EMR support replaces total absence of clinical information transfer

capabilities.

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Anna C. “Health Home” Experience

n  Comprehensive in home nurse practitioner BH clinician and PT and DME assessment produced the development, implementation and monitoring of the follow care plan:

n  72 hrs. of PCA support/week instituted for personal care, subsequently reduced to 40 hours/week overtime.

n  In home wound care nurse specialist consultation with a clinical management plan instituted.

n  Specialized air mattress delivered within 24 hours and motorized wheelchair with needed seating adaptations quickly arranged for.

n  In home BH assessment with individualized care plan created that includes medication (SSRI’s) and counseling.

n  Transportation arranged for specialty appointments, dental care and other activities.

n  Smoking cessation strategies instituted. n  Primary care physician identified with continuous support by a nurse

practitioner provided as a first responder to, and clinical management of, new problems via home visits.

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Anna C. - One Year Later

n  Engagement with life, family, community and in self management greatly improved. Withdrawal and despondency diminished.

n  Decubitus ulcers entirely healed. n  Effective BH psychopharmacology and LICSW in home counseling

relationship established. n  Smoking cessation efforts partially effective, frequency of asthma

exacerbations greatly diminished. n  Continuity relationship established with a PCP (through most

primary care occurs via RNP home visits) and with a Neurology consultant.

n  One year service use. q  2 ED visits for asthma exacerbation management. q  One three day hospitalization for urinary tract infections management.