Caring For Vulnerable Populations
2011 AHA Committee on Research Report
January 2012
Caring for Vulnerable Populations
An examination into emerging
and effective care coordination
practices for vulnerable
populations through the example
of caring for dual eligibles
1. Background on dual eligibles
2. Current programs to improve
coordination
3. Core elements in care coordination
programs
4. Future policy developments that
may help improve care coordination
Report available at: www.aha.org/caring/
AHA Committee on Research: http://www.aha.org/research/cor/index.shtml
© 2011 American Hospital Association
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Who are Dual Eligibles?
9.2 million Americans are dual eligibles: Medicaid beneficiaries who
are also enrolled in Medicare. While 6 in 10 are 65 or older, more than
1/3 are younger individuals with disabilities.
As compared to traditional Medicare beneficiaries, dual eligibles are:






15% more likely to have a cognitive or mental impairment
50% more likely to have diabetes
600% more likely to reside in a nursing facility
250% more likely to have Alzheimer’s disease
100% more likely to have heart disease
Much less likely to receive specific measures of preventive care,
follow-up care or testing
Sources: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and
Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, http://www.kff.org/medicaid/8081.cfm, July, 2010. Milligan, CJ et al.
“Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer,” The Commonwealth Fund, February 2008. Grabowski, DC. “Special Needs Plans and
the Coordination of Benefits and Services for Dual Eligibles,” Health Affairs, 28 no. 1(2009): 136-146.
© 2011 American Hospital Association
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Since Dual Eligibles Use More Health Care
Services . . .
Health service utilization among dual eligibles as compared to Medicare
population
56.4
Primary Care
69.5
60.3
Specialty
Physicians
72.9
13.1
Emergency Room
28.3
44.3
Outpatient Hospital
58.2
11.7
Inpatient Hospital
Medicare
Eligible Only
Dual Eligibles
17.9
2.6
5.2
5.1
9.8
Skilled Nursing
Facility
Home Health Care
0.4
0.8
Hospice
0
10
20
30
40
50
60
70
80
Percent of Population Utilizing the Service
Source: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for
Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, July, 2010. Accessed
at: http://www.kff.org/medicaid/8081.cfm,
© 2011 American Hospital Association
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…They Account for a Disproportionate Share
of Spending
Dual Eligibles as a Share of 2006
Medicare Population and Spending
84%
16%
Total Medicare
Population, 2006:
43 million
Dual Eligibles as a Share of 2007
Medicaid Population and Spending
61%
73%
85%
39%
27%
15%
Total Medicare FFS
Spending, 2006:
$299 Billion
Total Medicaid
Population, 2007:
58 million
Dual Eligibles
Total Medicaid FFS
Spending, 2007:
$311 Billion
Non Duals
Source: Kaiser Family Foundation, “The Role of Medicare for the People Dually Eligible for Medicare and Medicaid,” January 2011.
http://www.kff.org/medicare/upload/8138.pdf
© 2011 American Hospital Association
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Existing Service Delivery Models Lack
Coordination at the Provider Level
Program
Financing
Risk-adjusted,
capitated payments
Special
to cover all Medicare
Need Plans services (each plan
determines Medicaid
involvement)
Program of
AllInclusive
Care for
the Elderly
Medicaid
Managed
Care
Separate Medicare
and Medicaid
capitated benefit at
an agreed-upon per
member per month
rate
Some plans maintain
FFS with additional
payment for
coordination; others
use capitated model
Population
Care Coordination
298 plans
serving more
than 1,000,000
beneficiaries
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



Patient ease through one plan
Greater budget predictability
Multidisciplinary care team
No proven care improvement
Varying degree of Medicaid coordination
71 sites
nationally,
servicing
approximately
23,000
participants
Approximately
2.5 million
beneficiaries
+










Fully integrated funding stream
Established quality measures
Medical and nonmedical capabilities
Sufficient up-front capital required
High administration and workforce costs
Centered on one physical location
Incremental step toward risk sharing
Improved care coordination
FFS disincentives remain
No set design standard
Some exclusion of long-term care and
behavioral health benefits
Sources: (1) Milligan, C et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer.” The Commonwealth Fund. February, 2008. (2)
Centers for Medicare and Medicaid Services. Special Needs Plan Comprehensive Report: Medicare Advantage/ Part D Contract and Enrollment Data,
Special Needs Plan Data. Accessed at: http://www.cms.gov/(3) McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American
Hospital Association Committee on Research, Chicago, IL, March 2011). (4) Petigara, T et al. “Program of All-Inclusive Care for the Elderly.” Health
Policy Monitor. April, 2009.
© 2011 American Hospital Association
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Affordable Care Act Offers Opportunities to
Improve Dual Care Coordination

The Federal Coordination Health Care Office will
study and analyze the best methods to integrate
dual benefits, improving coordination between the
federal and state governments.

The Center for Medicare and Medicaid Innovation
will test innovative payment and service delivery
models to improve quality and reduce unnecessary
costs. In April it was announced the selection of 15
states to receive financial assistance to improve
care coordination across sites of care for the dual
eligible population.
© 2011 American Hospital Association
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Hospital Strategies to Care for Duals
Incorporate Several Essential Elements
Complete assessments
1 and reassessments
Align financial incentives
7
Incorporate person-
Develop network and
community partnerships
8
Implement protocolbased planning
Provide nonhealth care
services
9
4 Conduct periodic visits
Offer home-based care
10
Utilize team-based care
Organize center-based
day care
11
Facilitate data sharing
and integrated
information systems
Incorporate cultural
competency and equity of
care standards
2 centered care principles
3
5 management
6
© 2011 American Hospital Association
Offer home-based care
8
12
Core Element 1: Complete Comprehensive
Assessments and Reassessments
1
A comprehensive assessment
identifies all
potential
and 7
Align
financialmedical
incentives
psychosocial supports aids
necessary for an individualized care
Develop network and
8
plan. Comprehensive
programs
community partnerships
typically include annual
Provideassessments
nonhealth careto
comprehensive
9
services
evaluate any
change in the patient’s
clinical or social needs.
Offer home-based care
10
Complete assessment
and reassessment
Incorporate person-
2 centered care principles
Implement protocol-based
3 planning
4 Conduct periodic visits
Example: Johns Hopkins ElderPlus Program
Utilize
team-based care
center-based
Individualized
care plan is designed uponOrganize
admittance
to
5 management
day care
the program based on a comprehensive medical and
behavioral
assessment.
Facilitate
data sharing
Incorporate cultural
staff (including everyonecompetency
from
integrated
and equity of
6 andMultidisciplinary
information
systems
careworkers)
standards
physicians
to housekeeping aids and social
hold quarterly intake meetings to monitor care.
Sources: (McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago,
IL, March 2011). Jaffe, S. “Federal Program Aims to Keep Seniors out of Hospitals and Nursing Homes.” The Washington Post. December 20, 2010.
© 2011 American Hospital Association
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11
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Core Element 2: Incorporate PersonCentered Care Principles and Practices
Place the individual and affiliated 7
family and friends (including
informal caregivers, client
advocates, and peers) at the center 8
of all planning decisions to achieve
better results and promote patient 9
self-direction.
1
2
Incorporate personcentered care principles
3
4
10

5
Each patient works with a nonclinical health coach to proactively
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manage care, making contact once every two weeks.
New patients receive hour-long appointments, existing 30 minutes
12
Patients guaranteed same-day sick visits, follow-up call within 24 hours
Patients have no copayments for physician visits or prescriptions filled
at on-site pharmacy
Example: AtlantiCare Special Care Center

6

Sources: Gawande, A. “The Hot Spotters: Can we Lower Medical Costs by Giving the Neediest Patients Better Care?” The New Yorker. January 24, 2011.
Blash, L et al. “The Special Care Center: A Joint Venture to Address Chronic Disease.” Center for the Health Professions Research Brief. February, 2011. Page,
L. “10 Ways Atlanticare’s Special Care Center Improves Outcomes and Lowers Costs.” Becker’s Hospital Review. February 4, 2011.
© 2011 American Hospital Association
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Core Element 3: Implement Protocol-Based
Planning
Evaluate and employ evidencebased protocols to manage common7
conditions affecting geriatric and
other vulnerable populations,
8
reducing unwarranted provider
variation.
9
1
2
3
4
Implement protocol-based
planning
Example: BOOST Program at SSM St. Mary’s Medical Center
5 1.
2.
3.
6
Charts flagged upon admission for eligible patients
Names added to a white board for provider tracking
Discharge process completed together by a physician and a
nurse using the “teach back” technique.
4. Patient receives all discharge information on a one-page
document to bring back to primary care physician.
BOOST = Better Outcomes for Older Adults through Safe Transitions
Sources: Budnitz, Tina. “Project Boost: Reducing Unnecessary Readmissions and so much More.” Society of Hospital Medicine. Available at
www.hospitalmedicine.org/BOOST. Wellikson, L et al. “Aligning Hospitalists & PCPs: Coordination and Transitions” (presentation, American Hospital
Association Committee on Research, Chicago, IL, March 2011).
© 2011 American Hospital Association
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10
11
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Core Element 4:Conduct Periodic Visits
1 Include periodic visits (in person, by telephone, or via internet)
with the patient and his or her family/ caregivers in their own
home, complementing regularly scheduled medical care.
2
Example: GRACE, Wishard Health Services
3
4
Conduct periodic visits
5
6
8
9
Visit frequency varies but typically includes:
1. Comprehensive in-home assessment by10
nurse practitioner and social worker
2. In-home visit after care plan development
11
to discuss logistics
3. Phone contact at least once per month by
12
GRACE coordinators
4. Home visit after each hospitalization or
ED visit.
GRACE = Geriatric Resources for Assessment and Care of Elders
Sources: Bielaszka-DuVernay, C. “The ‘GRACE’ Model: In-Home Assessments Lead to Better Care for Dual Eligibles.” Health Affairs, 30, no. 3 (2011): 431444. Counsell, SR et al. “GRACE: Geriatric Resources for Assessment and Care of Elders.” (presentation, Health Affairs, January, 2011). “IU Geriatrics.”
Presentation provided by Stephen R. Counsell.
© 2011 American Hospital Association
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12
Core Element 5: Utilize Team-Based Care
Management Centered on Primary Care
Coordinate medical, behavioral, and long-term support services
through the work of a multidisciplinary, accountable, and
communicative care team. Integrate primary care physicians as the
2 core of the care team, supporting and collaborating with the
multidisciplinary group.
1
3
Example: Commonwealth Care Alliance
4
5
Utilize team-based care
management
6
8
9
Multidisciplinary primary care that includes
10
the following components:
1. Comprehensive assessments
2. Individualized care plans with integrated11
behavioral health
3. Team trained in social issues
12
4. RN, NP, behavioral health, MSW, and
PCP assigned to each patient.
5. Capacity for home visits
Sources: “Plan-Funded Team Coordinates Enhanced Primary Care and Support Services for At-Risk Seniors, Reducing Hospitalizations and Emergency
Department Visits.” AHRQ Health Care Innovations Exchange. Accessed July 11, 2011. Simon, Lois. “Commonwealth Care Alliance: The Case for Primary
Care Redesign and Enhancement as the Critical Strategy to Improve Care and Manage Costs” (presentation, Alliance for Health Reform Briefing, August,
2011).
© 2011 American Hospital Association
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13
Core Element 6: Facilitate Data Sharing and
Integrated Information Systems
1 Provide mechanisms and
create the necessary
data-sharing
2
arrangements to collect,
store, integrate, analyze,
3 and report data in a timely
manner to promote care
4 coordination.
Example: Montefiore Care Management
Organization



5
6
Facilitate data sharing
and integrated
information systems

Utilizes a data warehouse to
measure quality of care for
specific patient population.
Combines claims with clinical
data to identify patients that
necessitate increased care
coordination.
Payer data facilitates ability to
follow patients when they leave
the Montefiore System.
Examine ED visits,
readmissions, medication
compliance.
Sources: Gardner, E. “Montefiore Medical Center: On the Cutting Edge of Accountable Care.” Modern Healthcare Insights. 2011. Chase, D et al.
“Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations.” Commonwealth Fund: High-Performing Health Care Organization.
October, 2010. Czinger, P. “Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care.” (presentation, Bipartisan
Policy Center’s Health IT and Delivery System Transformation Summit, Washington, DC, June 27, 2011).
© 2011 American Hospital Association
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7
8
9
10
11
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Core Element 7: Align Financial Incentives
1
2
Organize financial
arrangements and potential
savings to encourage
cooperation and alignment
across the continuum of care.
Align financial incentives
8
3
4
9
Example: Fairview Partners at Fairview Health Services
•
5
•
6
7
Fairview Partners receives a per member, per month
payment to provide comprehensive care for all
services.
Net income is distributed to its three partnerships, and
Fairview assumes full operational responsibility for the
continuum of care.
Sources: “Conrad, J et al. “Fairview Partners” (presentation, American Hospital Association Committee on Research, March 2011).
© 2011 American Hospital Association
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10
11
12
Core Element 8: Develop Network and
Community Partnerships
Expand beyond the hospital and
1encourage relationships with
nursing homes and long-term care
providers, public health
2departments, community centers,
and other organizations to
3improve care coordination and
transitions
7
Develop network and
community partnerships
4Example: The Care Coordination Network at Summa Health System
8
9
10
Summa worked with representatives from 28 area SNFs, EMS services,
5and the local agency on aging to create a task force with three main
11
objectives:
6 1. Standardize the SNF referral process with evidence-based guidelines
12
2. Create a clinical subcommittee to improve care transitions
3. Design and evaluate outcome measures to monitor network
performance
McCarthy, D et al. “Case Study: Summa Health System’s Care Coordination Network.” The Commonwealth Fund. Accessed August 23, 2011.
“Cooperative
Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of
Hospital Stays.” AHRQ Health Care Innovations Exchange. Accessed September 9, 2011
© 2011 American Hospital Association
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Elements Incorporated Into The Most
Integrated Programs
1
7
Provide nonclinical services such
2 as transportation to medical
appointments.
8
3
Incorporate timely, patient- and
family-centric, home-based care
4 options
5 Form or partner with a program
that utilizes a center-based model
6
Develop care teams with
awareness of the individual’s
cultural perspective and language
fluency.
© 2011 American Hospital Association
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Provide nonhealth care
services
9
Offer home-based care
10
Organize center-based
day care
11
Incorporate cultural
competency and equity of
care standards
12
Measure Progress Through Performance
Metrics
Type of
Measure
Utilization
Relevant Metrics to Measure Program Process




Number of ED visits
Number of hospital admissions
Number of preventable admissions
Number of surgical procedures


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

Length of survival
Assessing Care of Vulnerable Elders
(ACOVE) measures
SF-36 Questionnaire or similar scale
Medication compliance
Total cost of care
Cost per inpatient hospital stay
Cost of specialty care visits
Cost of primary care visits
Mental health care spending
Patient satisfaction in all settings –
inpatient (HCAHPS), ambulatory,
nursing home
Affiliated partner satisfaction

Quality and
Outcomes 
Cost







Satisfaction

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
Number of labs and tests ordered
Number of missed appointments
Hospital length of stay
Electronic health record meaningful
use
Assisted Daily Living (ADL)
improvement
Hospital Compare – process of
care measures
Mortality
Durable medical equipment costs
Nonhealth care service spending
Cost of employed care coordinators
Home health care costs
Provider satisfaction
Patient satisfaction
Patient family/ caregiver
satisfaction
Applicable metrics will vary by program implemented
© 2011 American Hospital Association
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Key Take-Away: Caring for Vulnerable
Populations
While financial alignment
may occur at a policy
level, hospitals are well
positioned to address
the system, provider, and
patient barriers impeding
high-quality care for the
most vulnerable
populations.
Report available at: www.aha.org/caring
AHA Committee on Research: http://www.aha.org/research/cor/index.shtml
Contact: Jill Seidman at jseidman@aha.org / 312-422-2641
© 2011 American Hospital Association
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