Vanessa Oddo, Angela Gerolamo, David R. Mann and Catherine DesRoches
Mathematica Policy Research
Although people with disabilities make up 15 percent of the Medicaid population, they account for more than 40 percent of expenditures (Kaiser Commission on Medicaid and the Uninsured September 2012). These individuals often have unique health care and social needs, requiring care from multiple providers across a wide range of settings, which makes coordination of care particularly important. Although results are mixed, designating one provider or organization to coordinate care and facilitate patient self-management could be a promising approach to improving care for people with disabilities (Brown 2009; Gravelle et al. 2007; Smith et al. 2005). Despite the challenges of coordinating care for people with disabilities, a few programs have a long history of trying to better serve this population--these programs are referred to as disability competent managed care plans. This report describes the organizational features of three disability competent health systems: Commonwealth Care Alliance's (CCA) two plans, Boston's Community Medical Group (BCMG) and Senior Care Option (SCO) in Massachusetts, Community Health Partnership (CHP) in Wisconsin, and the Independence Care System (ICS) in New York City. We describe the organizational features of these plans and the ways in which staff deliver services and coordinate care for people with disabilities. This report also serves as a useful guide to program operators interested in refining or implementing a care coordination model for people with disabilities.
To better understand the facets of this model, we conducted two-day site visits to each program. The disability competent managed care plans described in this report are committed to promoting independence and individualized care among their members, and to ensuring that members have the appropriate balance of medical and social supports. The plans also share four key features: (1) high-touch clinical interventions; (2) interdisciplinary teams to deliver care; (3) a strong emphasis on managing care transitions; and (4) investment in behavioral health resources. Although contact varies based on need and is guided by clinical judgment, the plans generally provide frequent in-person contact between the provider and the member. In some cases, providers visit members once per month. Each plan uses a team made up of various staff members who have the knowledge and skills to best meet the needs of the population and to serve as a resource to other staff. The plans' emphasis on care transitions is supported in two ways: (1) all of the plans have established a formal protocol for managing care transitions; and (2) all have dedicated personnel to this role. In addition, the plans unanimously reported the prevalence of behavioral health problems among their members; three of four plans employ behavioral health personnel to work directly with members and care coordinators, and all plans encourage care coordinators to consult with behavioral health personnel, as needed.
While the plans share these common features regarding how they are implemented, they differ on three other important operational features: (1) their level of integration with primary care and other providers; (2) the intensity of specialized services provided; and (3) the sophistication of information systems and data monitoring. The level of integration with primary care and other providers varies across the plans. CCA-SCO recruits primary care practices and "wraps the care team around the practice" such that it is highly integrated with the practice. Less integrated operations are evident at BCMG, CHP, and ICS. BCMG and ICS primarily serve people with disabilities, whereas CHP and CCA-SCO serve broader populations. Thus, ICS and BCMG devote considerable resources specifically to assist staff in working with individuals with disabilities. Although all the plans use member feedback to inform change, two of the plans employ a more data-driven approach to providing services and monitoring members; CCA-SCO and CHP use their information systems to generate sophisticated monitoring reports. In addition, BCMG and CCA-SCO staff have access to patients' electronic medical records, which significantly enhances care coordination activities with external providers.
The programs in this study incorporate features that define what it means to be an effective disability competent system, including coordinating services with providers across various settings, individualizing care based on members' needs, involving members in clinical decision-making, incorporating members' feedback into the program, and monitoring outcomes to drive change. Our study identified four factors, present in all of the plans, that helped the plans operationalize these core features: (1) high-touch clinical interventions; (2) the use of interdisciplinary teams; (3) a strong emphasis on managing care transitions; and (4) investment in behavioral health resources. The first three features are among those that have been found in programs that successfully reduced hospitalization for high-risk Medicare beneficiaries in a fee-for-service environment. However, programs must tailor their models based on the populations served and the complex settings in which they operate. Further, policymakers could play a critical role in the sustainability of these programs, because the state-specific policy context and reimbursement structure in which plans operate greatly affects their ability to deliver interventions and their financial viability. Although the plans must continue to explore cost-effective ways to deliver their interventions, in order to generate net savings, policymakers should consider removing the legal and regulatory limitations that increase administrative burden and reduce the effectiveness of plans. Policymakers could also consider compensating plans for care coordination activities to improve the financial viability of these relatively small plans. Program administrators should systematically monitor outcomes that are relevant for members of disability competent systems such as quality of life, member satisfaction, and functioning. Monitoring critical outcomes that are specific to individuals with disabilities would enable program operators to more fully assess their programs. Our study reinforces the importance of developing population-specific programs; program administrators must tap particular health and social services in order to improve the health and quality of life of individuals with disabilities.
These programs continue to adapt to both external changes, such as the changing state and federal health care landscapes, and internal quality improvement changes based on data as well as their own experiences. This dynamic aspect is noteworthy because it is not only the facets of the programs, but also the continued refinement of their programmatic details and their leaders' adaptability that contribute to their ability to meet the unique needs of individuals with disabilities.
|The Full Report is also available from the DALTCP website (http://aspe.hhs.gov/office_specific/daltcp.cfm) or directly at http://aspe.hhs.gov/daltcp/reports/2014/3MCPlans.shtml.|