Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 2. Assessments


Assessments are the key step in linking identification efforts to the delivery of effective care. Furthermore, assessments address the variability among high-risk seniors so that MCOs and providers can tailor interventions to meet each person’s specific needs. In general, MCOs will combine a quick general assessment with their identification efforts. This general assessment uses the screening information to determine if someone is likely to need the intense and comprehensive services of a care manager, the focused interventions of disease management, or other services. If a thorough assessment is required, it is done as part of the care management process.

To a large extent, the MCOs relied on the primary care physicians to do much of the assessment. These assessments were generally done in the course of routine office visits and were based on the physicians’ judgments about individuals’ conditions and appropriate treatments. However, when high-risk seniors were identified through screening and other identification efforts, the MCOs arranged for additional assessments. In addition, when physicians felt that a senior required substantial community support or other non-medical care, they could refer that person to a care manager or other professional who could assess those types of needs and help arrange for care. For those seniors identified through MCO high-risk identification processes, the first step was to identify those individuals who have a specific high-risk condition but who were in fairly good shape, with no mental or physical impairments. Assessments for these people emphasized ongoing monitoring so that subsequent impairments or symptoms could be detected and addressed quickly. A more complex situation involved those people who, to maintain functioning, required social support services outside the Medicare benefit package. The MCOs tended to address these needs by identifying the appropriate community agencies and referring people to them. The most difficult cases were those involving high-risk seniors with several chronic conditions and impairments. These cases were first identified in a quick review of the screening or other identification information and then referred to the organization’s care management program for a more thorough assessment. Care management staff evaluated the high-risk seniors’ medical and psychosocial needs, which are often intertwined. They also assessed the seniors’ home and informal support situation in terms of the availability of competent caregivers, the degree of physical safety, and evidence of abuse. The care managers then developed a care plan, worked to ensure that it was implemented, and monitored the people for changes in their health or functioning.

The four case study organizations rarely arranged for formal geriatric assessment clinics. This is generally true in Medicare managed care, because of the high costs and lack of clear evidence about the cost-effectiveness of such assessments. Among the four case study organizations, we observed no efforts to establish geriatric assessment programs such as specialized clinics or inpatient units. Two organizations, however, appeared to emphasize special geriatric training as part of their staff composition. For example, a high proportion of physicians at both Aspen and Kaiser Colorado had an additional qualification in geriatric medicine. These physicians were more likely to use assessment tools and approaches similar to formal assessment, even though there were no specially designed assessment programs.

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