PCPs, health plans co-manage dual eligibles
Information sharing key to program’s success
By sharing information and collaborating on patient care, Atrius Health and two health plans are coordinating care for patients who are eligible for both Medicare and Medicaid benefits.
Patients who are eligible for both Medicare and Medicaid tend to have complex conditions as well as psychosocial issues that interfere with getting care and following their treatment plan, says Emily Brower, executive director of Accountable Care Programs for Atrius Health, a nonprofit alliance of six multispecialty medical groups and one home health and hospice agency in eastern and central Massachusetts.
"Our dually eligible patients definitely need a lot of home and community-based support in getting access to care and supporting their care plan," she says.
The organization analyzed its patients who were dually eligible for Medicare and Medicaid and found that they fell into two distinctly different groups, Brower says. Dual eligibles who were over 65 were similar to the rest of the Medicare population, but their chronic diseases tended to be more complex and challenging. Those under 65 had a higher incidence of behavioral health conditions, including substance abuse, she says.
Atrius Health partnered with Commonwealth Care Alliance to provide coverage and services for its dual eligible patients under 65, and Tufts Health Plan for patients over 65, she says. Atrius Health’s physician practices provide the medical care for the patients in the program. The health plan case managers see the patients in person, connect them with the social supports they need, and work with the physician practice case managers to make sure the patients get all the services they need. Case managers from the health plans and from the physician practice will have regular conference calls to review cases that are active and collaborate on meeting the patient needs, she says.
Before the recently launched collaboration started, Atrius Health staff held a series of working meetings with representatives from the health plans to develop a model that ensures that the health plans and physician practices share information that enables them both to provide better care and care coordination for the patients in the program, Brower says.
"Communication is the glue that holds this model together. With that communication, we’ll know what is going on with patients, know the patients’ goals, and work together to help the patients meet their goals and stay healthy," Brower says.
Atrius Health gives health plan case managers access to the enrolled patients’ medical records so they can understand the clinical picture before contacting the patients, she says.
When patients join the program, the health plan case managers review the medical record and make notes of lab values, blood pressure control, gaps in care, and any services the patient is receiving from the primary care clinic, such as nutritionist visits or a diabetes program, Brower says.
Armed with this knowledge, says Brower, the case managers will visit each patient at home, conduct a comprehensive assessment of medical and psychosocial needs, and review the patient’s medication, checking a list from the physician office, and go over it with the patient, adding any over-the-counter medications or other substances he or she is taking.
In the case of people over 65, the case managers may also check for throw rugs, electric cords, and other fall risks and make sure the bathroom is accessible, Brower says.
Case managers work with the patients to set goals, work with them on strategies to meet the goals, and reinforce the information they have received from their physician office, according to Brower.
For instance, if the patient has been meeting with a nutritionist in the physician office, the case manager may ask about the patient’s diet, what kind of meals he or she eats and who cooks the food, then go over the nutritionist’s instructions.
After the initial meeting in the patient’s home, Brower says, the health plan case manager follows up at regular intervals, either in person or by telephone depending on the patient’s needs.
Commonwealth Care Alliance has a lot of experience coordinating care for disabled patients who are under the age 65, Brower says. "Many of these patients have behavioral health issues. We partnered with an organization that has a strong relationship with mental health providers to round out our network of service and to complement the services we provide. We are also fortunate to partner with Tufts Health Plan, which has been working with us on other programs for seniors for many years," she says.
When the health plan case managers complete an assessment, they share information about what is going on in the patient’s home, what kind of support is in place, safety issues, barriers to care, and other details that will be helpful for the physician to know, she says.
"There’s a real benefit to our collaboration because we get the whole picture of a patient. We start with the clinical picture in the patient’s medical record and complement it with what the health plan case managers see in the home, such as social support and patient needs," she says.
The physician practice and the health plans manage the patient together and each participates in meeting a common goal, Brower says. "This program integrates medical and clinical needs with the patients’ needs at home and in the community and provides care for the whole patient," she adds.
"We are the medical experts and partner with the health plans for expertise in community-based support. In general, we provide the medical services and the health plan provides the community-based support, but there is a lot of overlap," Brower says.
For instance, Atrius Health has a strong program for patients with diabetes, Brower says. Atrius medical group staff provide patient education about the disease and how patients can self-manage. "The health plan case managers reinforce the diabetes education we provide when they see the patients in their homes and work with patients on developing goals that are important to them. We work together to bring in other resources when available, and each organization reinforces the others’ work with the patients," she says.