CountyCare deploys care coordinators who work out in the field with the patient and the care team to identify goals, desired outcomes and tasks that a patient may complete, said Steven Glass, CountyCare's executive director of managed care. Because behavioral health diagnoses are one of the top reasons its patients end up in the ER, the plan also partnered with several local behavioral healthcare providers last year to ensure patients see a mental health provider or substance use specialist within 48 to 72 hours of referral.
Partnering with healthcare providers is key to creating patient buy-in, said Christopher Stanley, director of the healthcare practice at consulting firm Navigant. "Many health plans have realized that the trust factor with health plans and patients is not particularly strong," he said.
CountyCare is also set to launch two programs this year that aim to help members facing housing and food insecurity. CountyCare estimates that a fifth of its members are homeless and 17% find it difficult to keep food in the pantry by the end of the month. So the plan is partnering with Housing Forward, an Illinois provider of supportive housing services, to help homeless members find stable housing. It also is launching a program where care coordinators are able to bring boxes of shelf-stable food to plan members at their discretion, in partnership with another provider. Patients who are discharged after an inpatient stay will be eligible for up to two weeks of home-delivered meals.
Like CountyCare, more health plans are beginning to address patients' nonclinical social determinants of health, like housing or meals, which are critical in the Medicaid and Medicare Advantage populations, said Rachel Sokol, a practice manager at consultancy the Advisory Board Co.
"Everyone is focused on it from a one-off perspective," Sokol said, but "what's innovative is when organizations start to contract with some of these community organizations, using a local housing facility to do outreach . . . or using meal delivery as a covered service."
Before Commonwealth Care Alliance addresses patient's medical issues, it tackles social determinants of health, then mental health conditions, said Christopher Palmieri, the Boston-based health plan's CEO. That pecking order is necessary because for someone who is facing homelessness, "having a warm place to sleep or hot meal are more important than having your diabetes managed." Moreover, a patient with a severe mental illness will have a tough time complying with a care plan.
Commonwealth Care Alliance serves 13,000 dually eligible members under a Medicare-Medicaid program called One Care. A third of the program's members account for 70% of the costs. The members have complex needs: Nearly three quarters of them have a household income below $20,000, and 7% are homeless. About 70% have a serious mental illness, and 81% have two or more chronic conditions.
Patients are put at the center of their care and surrounded by teams including doctors, nurses and social workers. The member is "involved in their care planning, what type of care they get, what setting they prefer, who they want to work with, whether they prefer to get care in the home or in a traditional office or clinic-based setting," Palmieri said. The approach has led to a significant return on investment: A December 2016 study of 4,500 of One Care enrollees found that members enrolled for a year had 7.5% fewer hospital admissions and 6.4% fewer ER visits than in the 12 months prior to enrollment.
Different populations require different interventions, Navigant's Stanley said. What works for controlling spending among Medicaid members likely won't be effective for a Medicare Advantage population, he said. While Medicaid members tend to face barriers related to social determinants, Medicare Advantage members typically have several comorbid conditions.
Albuquerque-based integrated delivery system Presbyterian Healthcare Services launched its Complete Care program in 2015 to prevent catastrophic medical problems among seriously ill Medicare Advantage members who are in the last few years of their lives.