Perspectives: How Coordinated Care Improves Lives and Manages Costs
In this Perspectives, Dr. Chernof explains what recent polling results and coordinated care stories tell us about the experiences of Medicare-Medicaid individuals, and identifies opportunities to further strengthen and expand support.Date Updated: 01/12/2016
Starting last summer, the Field Research Corporation released two polls tracking experiences and perceptions of Californians enrolled in Medicare and Medi-Cal, the dually eligible. About 5,000 people participated with views from those enrolled in the state’s duals integration pilot and those choosing not to change their Medicare. What have we learned so far? Contrary to the traditional narrative that people face challenges when transitioning to new care models, the vast majority of those in the pilot are satisfied, have access to doctors and hospitals they want, and express confidence in their care. While results show that the initial transition has been smooth for many, these also point to areas where more work must be done by state and health plan leaders, including clearer materials, additional education, and continued development of comprehensive care coordination models.
While polling provides a meaningful, population-level perspective, it cannot convey the powerful impact that care coordination has on the daily lives of people relying on these programs. Therefore, The SCAN Foundation supported Collaborative Consulting to talk with dually eligible Californians who shared their stories about how coordinated care changed their lives. Each story shows the human connection needed to make a person-centered care approach come to life while delivering on the Triple Aim—a healthier population, a better personal experience, and lower per capita costs.
Taken as a group, what do these stories teach us?
1) When services operate in their own silos, both people and payers experience significant risk for poor and costly care. Enormous efforts have been made to measure and improve the quality of medical care, focused almost entirely on doctors and hospitals, procedures, and diseases. Medical quality improvement has focused on reducing risks, through tools like sentinel event identification and root cause analysis. In truth, the same or greater challenges exist in the community-based environment where most dually eligible individuals spend the vast majority of their lives. If good care coordination and support do not exist, avoidable use of medical services increases, leaving people at risk of poor outcomes. Therefore, the same systematic attention to quality is needed for the full continuum of services. The reality is that most dually eligible individuals can articulate the quality challenges they experience quite clearly, where as we as providers have a much harder time seeing it.
2) Many of these individuals have faced long-standing economic and service access challenges. Income eligibility for Medi-Cal means that last year, a single adult had less than $16,243 annually and less than $2,000 in savings. Thus, being dually eligible often means having serious health and daily living challenges in the face of real poverty. They cobble together plans of care—or go without care altogether—and small changes in personal circumstances or timely access to services can create large negative outcomes. Without considering social determinants of health when designing care delivery, the backstop for these individuals to get their needs met can be the most expensive option: the emergency department.
3) Care coordination that spans medical and social needs changes lives. As a group, these stories show that care coordination can improve outcomes while supporting independence and restoring dignity. The five people who shared their stories all want to avoid unnecessary health care use where possible. Each described that maintaining and maximizing function is first and foremost in their lives. They reiterated that having engaged daily lives as they define it is more important than the mechanics oftheir medical problems and care plan processes that providers care so much about.
Finally, what about next steps for this population?
The polling and stories show that lives were improved and unnecessary health care was avoided through increased care coordination, yet opportunities to strengthen and expand support remains. For most, care coordination is often built in reaction to an event. We believe it should be more proactive and occur prior to an acute issue where possible. This calls for information systems and standardized assessment processes to identify people at risk for negative outcomes and outreaching to them preemptively. Also, new care models are embracing community-based services as the focal point, particularly those required by the duals pilot. This work must go further to break down silos that still exist between mandated services and expand the range of available optional services (e.g., home modifications) to enhance community living for people with high levels of need. The journey has begun from patient-centered care to person-centered care. The voices of Californians who depend on Medi-Cal with Medicare can help map the way.
Bruce Chernof, MD, President and CEO of The SCAN Foundation, dedicated to creating a society where older adults can access health and supportive services of their choosing to meet their needs. The Perspectives Series provides opinions and observations about transforming the way in which we age. Follow Dr. Bruce on Twitter @DrBruce_TSF.
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