Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 1. Key Characteristics of High-Risk Seniors and the MCOs That Serve Them


Our study of high-risk seniors is organized around concepts identified by the acronyms VIP and I-CAN (Figure I.1). VIP stands for three key population characteristics that will challenge any system that tries to serve high-risk seniors:

  • Variability. High-risk seniors often differ substantially from one another, and their conditions and symptoms often vary over time. Not only do they have varying mixes of conditions and impairments, but their attitudes and their capacities for self-care differ widely. As a result, individualized care plans (rather than standard protocols) often must be developed to fit each person’s profile.

  • Impairments. Most high-risk seniors have impairments that make them more difficult to serve than the general senior population. In particular, physical and cognitive impairments can make it hard for these seniors to access the care system effectively and, in some cases, to care for themselves. People often have multiple conditions that require organizationally complex care and place them at high risk for developing additional conditions or impairments. Finally, impairments are likely to worsen over time, and the impairments of some seniors will be sufficiently severe that they find it difficult to care for themselves or to live independently.

  • Providers. High-risk seniors tend to have numerous providers and receive services in many settings, including physicians’ offices, hospitals, nursing homes, and their own homes. This diversity of provider types and settings also leads to organizationally complex care.

I-CAN stands for care system features that MCOs can use to respond effectively to the needs of high-risk seniors:

  • Identification. No targeted services are possible without initial identification of those seniors who are at high risk. This can be done through screening that uses surveys or administrative data, by providers in the course of delivering care, by monitoring hospital admissions to find people who have developed serious illness with substantial sequelae, and through general outreach activities designed to encourage self-identification by high-risk seniors. Identification systems also need to include some sort of general assessment system in order to refer identified people to the appropriate services, including more detailed assessment.

  • Care Management. This type of service strives to make organizationally complex care more efficient and more manageable for the seniors and providers. It begins typically with a detailed assessment of people’s needs and then helps to coordinate care delivery among multiple providers and facilitates referral to and follow-up with appropriate social service providers. It can also educate patients about monitoring their conditions and about improving their self-care and lifestyles.

  • Assistance Programs. These programs are aimed at seniors with specific needs who generally do not require the intensive efforts of care management. Because of the variability among seniors, a wide array of assistance programs exists. These include many types of disease management to address difficulties adhering to treatment regimens for specific diseases (like diabetes or heart failure), pharmacy programs that look for possible drug interactions or more efficient drug combinations, general health promotion and disease prevention programs, behavioral health screening and referral, and volunteer programs that address social isolation.

  • Networks. MCOs can also promote better care for high-risk seniors by the way they build and run their networks. This includes recruiting geriatricians or other providers with specialized knowledge and skills for treating seniors. MCOs can also selectively contract with skilled nursing homes or other providers in order to ensure quality and to promote better coordination of care. Finally, MCOs can try to influence care delivery by compensating providers in particular ways, or by developing systems to foster information sharing among providers.

FIGURE I.1. The "VIP" Needs of High-Risk Seniors and "I-Can" Responses
Characteristics of High-Risk Seniors: MCOs Can Respond with:
  • Variation in needs, abilities, and attitudes:
    • Among high-risk seniors
    • Over time



  • Reduced stamina, ambulation difficulties, and limited driving ability that make it difficult to access care
  • Sensory and cognitive impairments that can impede self-monitoring and communicating with providers
  • Multiple chronic and acute conditions
  • High risk for developing additional conditions and impairments
  • Limitations in self-care and independent living



  • Use of multiple providers
  • Receipt of multiple services, often in multiple settings
  • Screening surveys
  • Review of administrative data
  • Provider referral
  • Inpatient admissions
  • General assessment


Care Management

  • Assessments
  • Care coordination
  • Referral to community agencies


Assistance Programs

  • Disease management
  • Expanded home health care
  • Pharmacy programs
  • Health education and prevention
  • Behavioral health
  • Volunteer programs



  • Physician recruitment
  • Selective contracting for facility care
  • Payment policies

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