Spring 2018 Generations

SPRING 2018 volume 42 number 1

Journal of the American Society on Aging

The hospital–CBO partnership: achieving the Triple Aim

Making the business case for CBO services

Shifts in mindset and practice— the key to partnerships

Fundamentals of Community-Based Managed Care: A Field Guide

Improve LTSS Operations.

Enhance Member Quality of Life.

Earning accreditation helps organizations: • Improve communication between organizations coordinating care, leading to better care integration. • Become more efficient by reducing errors and duplicated services. • Provide person-centered care, leading to better care planning and monitoring. • Support contracting needs by demonstrating their readiness to be trusted partners.

Organizations that provide coordination of long-term services and supports (LTSS) play a vital role in keeping people with disabling conditions and chronic illness as healthy and independent as possible. NCQA LTSS Accreditation programs are a roadmap for delivering integrated, efficient person-centered care. They guide improvement— organizations can use the standards as a gap analysis and focus activities in areas that are most important to individuals, payers and states. Accreditation program standards are based on industry best practices and include key areas:

Measurement and quality improvement

The assessment process

Care transitions

Person-centered care planning and monitoring

If you coordinate LTSS and want to improve the services provide to members, visit ncqa.org/asa or contact 202-350-1487 .

is the quarterly journal of the American Society on Aging.

Each issue is devoted to bringing together the most useful and current knowledge about a specific topic in the field of aging, with emphasis on practice, research, and policy.

Peer review consists of the following practice: the Genera- tions editorial board invites a guest editor, selected because of prominence within his or her subject area, to organize an issue of the publication around themes identified by the board. Authors are then proposed by the guest editor and are evaluated by the board on the basis of demon- strated knowledge, achievement, and excellence in their respec- tive fields. All manuscripts are reviewed by the guest editor, editor, and, when appropriate, members of the editorial board. As occurs in any peer review process, revisions may be re- quired, and articles that do not meet the editorial standards of Generations will not be published. Generations (ISSN 0738-7806) is published quarterly by the American Society on Aging, 575 Market Street, Suite 2100, San Francisco, California 94105-2869. www.generationsjournal.org www.asaging.org The American Society on Aging (ASA) is the essential resource to cultivate leadership, advance knowledge, and strengthen the skills of those who work with, and on behalf of, older adults.

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Postmaster: Send address changes to Generations , 575 Market Street, Suite 2100, San Francisco, California 94105-2869. The contents of Generations are indexed or abstracted in the following: Abstracts in Social Gerontology; AgeLine; CCCs Bibliographic Database; CARL UnCoverIngentaConnect; CINAHL Database (Cumulative Index to Nursing and Allied Health Literature); Current Contents/Social and Behavioral Sciences; Elsevier Bibliographic Databases; ERIC; Family & Society Studies Worldwide; Institute for Scientific Informa- tion Basic Social Sciences Index; Microsoft Academic Search (MAS); MLA International Bibliography; Research Alerts; SAGE Family Studies Abstracts; SCIE Care Data; Social Sciences Citation Index; Social SciSearch; Social Services Abstracts; Social Work Abstracts; Sociological Abstracts; Web of Science; Wilson Social Sciences Index/ Abstracts. For digital access to the current and back issues of Generations , visit Ingenta Connect at http:// www.ingentaconnect.com/content/ asag/gen.

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GENERATIONS – Journal of the American Society on Aging

ASA Executive Committee Chair, Board of Directors Karyne Jones, Washington, DC Chair-Elect Michael Adams, New York, NY Immediate Past Chair Robert B. Blancato, Washington, DC Secretary Robert E. Eckardt, Cleveland, OH Treasurer Lisa Gables, Alexandria, VA ASA Board of Directors Jean Accius, Washington, DC Cynthia Banks, Los Angeles, CA Richard Browdie, Cleveland, OH Scott Dingfeld, Omaha, NE Paul Downey, San Diego, CA Brian M. Duke, Radnor, PA Joyce Gallagher, Chicago, IL Maria Henke, Los Angeles, CA Brooke A. Hollister, San Francisco, CA Karen N. Kolb Flude, Chicago, IL Daniel Lai, Hong Kong Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Kevin Prindiville, Oakland, CA Deborah Royster, Washington, DC Phil Stafford, Bloomington, IA John M. Thompson, Atlanta, GA Joyce Walker, Richmond Heights, OH President and CEO Robert G. Stein, San Francisco, CA

GENERATIONS STAFF Publisher Robert G. Stein Editor

Alison Hood Senior Editor Alison Biggar Typography & Production Michael Zipkin | Lucid Design, Berkeley Generations cover and book design by Lisa Rosowsky, Blue Studio. Generations Editorial Advisory Board Susan C. Reinhard Chair Richard Browdie Immediate Past Chair Wendy Lustbader

Chair-Elect Jean Accius Gretchen Alkema Patrick Arbore Letia Boseman Louis Colbert Walter Dawson Brian Lindberg Robin Mockenhaupt Laura Mosqueda Kevin Prindiville Anne Tumlinson

Front cover image ©Gettyimages/dane_mark © 2018 American Society on Aging

2 | Spring 2018

Fundamentals of Community-Based Managed Care: A Field Guide

inside generations Fundamentals of Community-Based Managed Care: A Field Guide

building partnerships in community

50 Monitoring and Evaluation: Key Steps for Long-Term Services and Supports Organizations By Julie Solomon 56 Building a Strong Nonprofit Board Goes Beyond Best Practices By Gayle Northrop 61 Understanding Costs: How CBOs Can Build Business Acumen for Future Partnerships By Victor Tabbush 65 Shifts in Mindset and Practice Are Key to Cross-Sector Partnerships By Lori Peterson 69 Business Acumen in Government: One County AAA’s Healthcare Integration Experience By Jacob Bielecki 74 A Colorado-Based CBO Launches a Pilot to Keep People with Disabilities out of Nursing Homes By Patricia Yeager 79 Building Relationships and Reducing Barriers Through Building Business Acumen By Sue Tatangelo successful cbo models using business acumen to achieve success

4 The Community’s Emerging Role in Value-Based Health and Social Services By Margie Powers 9 The Value of the Hospital–CBO Partnership in Achieving the Triple Aim By Bonnie Subira 14 CareMore Health Tackles the Unmet Challenges of the Aging Population By Sachin H. Jain 19 CBOs and State Medicaid Programs: A Key Partnership for Patient-Centered Care By Danielle Garrett and Ann Hwang 24 Teaching CBOs to Develop Business Strategies By Erin C. Westphal 27 Making the Business Case for CBO Services By Victor Tabbush 32 A Matter of Mindset By Victor Tabbush 36 Strategies for Using Healthcare Dollars to Support Social Services By Laura M. Gottlieb and Victor Tabbush 41 Leading—Not Managing—Through a New World Order By Edward O’Neil 45 An Introduction to Marketing and Branding By Andres Terech

building business practices

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GENERATIONS – Journal of the American Society on Aging

The Community’s Emerging Role in Value-Based Health and Social Services By Margie Powers The role of community-based organizations is expanding as they partner with healthcare entities.

W ith the simultaneous movement in the healthcare industry toward value over vol- ume, and population-based health management, there is growing recognition that non-medical services are as important as those received in a provider’s office, especially for people with high needs, who engender high costs. Social determi- nants of health—economic stability; education and income status; access to healthcare, food, and housing; and environmentally safe communi- ties (Centers for Disease Control and Prevention, 2017)—are known to substantially determine negative or positive health outcomes, and have a disproportionate impact on health, compared to health behaviors and clinical care (Amarasing- ham, 2016). The combination of social, behavioral, and environmental factors contributes substantially to specifc health issues, including to more than 70 percent of some types of cancer, 80 percent of heart disease cases, and 90 percent of stroke

cases (Bradley et al., 2016). Healthcare organiza- tions are starting to more closely examine how to address social determinants’ impact on health, and one strategy is exploring closer partnerships with community-based organizations (CBO), ‘States with higher levels of spending on social services performed better on a list of health outcomes.’ establishing contracting relationships to support high-need, high-cost individuals. Traditionally, CBOs deliver services that aim to address the social needs of this population. While these services also can affect health, in most cases they are not directly reimbursed by plans or provider organizations. Given the cur- rent evolution of the healthcare industry, there is ample opportunity to develop cross-sector payment mechanisms to support high-need,

abstract Social determinants of health are known to impact health outcomes, and there is growing recognition that non-medical services are as important as those received in a provider’s office, espe- cially for high-need, high-cost populations. Healthcare organizations are exploring closer partnerships with community-based organizations (CBO), especially in support of this group. There is ample oppor- tunity to develop cross-sector payment mechanisms to support these individuals and to provide financial stability to valued community organizations. | key words: high-need, high-cost populations, CBOs, social determinants of health, Partners in Care

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Fundamentals of Community-Based Managed Care: A Field Guide

high-cost populations, while at the same time providing fnancial stability to valued commu- nity organizations. CBOs’ Role in Improving Health Outcomes CBOs by their nature have close ties with com- munities, and often work directly and intimately with people in their home setting, something healthcare providers are rarely able to do. This unique access gives CBOs insights into unmet social needs affecting health status, and even healthcare, hospital, and emergency department utilization patterns. A recent study showed that states with higher levels of spending on social services performed better on a list of health out­ comes than states with lower spending levels (Bradley et al., 2016). Older adults fnd that managing multiple health issues becomes more difficult when com- Table 1. CBO Services That Can Impact Health Interventions/Services Potential Impacts on Health Home visits to frail older adults and medically complex patients, provid- ing social support and companionship Consistent health mon­ itoring, even by non- licensed staff, can flag potential problems before they occur.

pounded by challenging social situations, and CBOs can play an important role in alleviating these stressors. For example, health problems can be worsened by a lack of adequate housing, nutrition, transportation, and family or care- giver support. If providers are aware of this, and can connect people to community services, clini- cal treatments are more likely to be successful. Many CBOs view themselves as “non-clinical,” but their services influence the health of high- need, high-cost people every day. Table 1 (on this page) shows examples of CBO services that can impact health outcomes. The Partnership for Healthy Outcomes (Miller, Nath, and Line, 2017) surveyed more than 200 organizations about their partnerships between healthcare organizations and CBOs. The survey revealed a wide variety of partner- ships, with no two alike; notably, the survey results also revealed a movement toward fnan- cial partnerships between organizations. Some key and promising fndings are as follows: √ Most partnerships focused on immediate clinical needs, such as care transitions, reducing readmissions, and length of stay; √ Most partnerships have a formal agree- ment between entities; √ A majority of partners (65 percent) report achieving some cost-savings as a result of the partnership; and √ Funding partnership programs is depen- dent upon multiple sources, but there is interest on both sides in creating a long-term sustainable funding model. CBOs are embracing their expanding roles in community health, but can struggle with secur- ing consistent funding sources to sustain their programs. They seek new payment mechanisms, yet have little expertise in negotiating payment arrangements between healthcare and non- medical service providers. They need guidance on how to integrate social services into the care Consistent, Sustainable Program Funding Is Key

Care coordination of transitions between home and hospital or skilled nursing facility

Assessing a person’s home, including adequate food and caregiver sup- port, can reduce readmis- sion risk. Instructing older adults and caregivers on how to reduce risk of falling can reduce accidents and hospital admissions. family and caregivers can improve quality of care for the individual. Ensuring people get necessary primary and follow-up care can reduce risk of hospitalization.

Falls prevention in the home for at-risk older adults

Caregiver respite services Providing support to

Transportation of older adults to medical appointments

Source: Pacific Business Group on Health, 2017.

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Table 2. Payment Methods for High-Cost, High-Need Populations

Payment Model


of high-need, high-cost individuals, as well as to create a reimbursement strategy to sustain these valuable programs. Existing payment models Traditionally, CBOs receive funding through government agencies or grants, which can be fnancially generous but are unpredictable, and dependent upon the changing priorities of the government and funders. Another challenge is that funding often is limited to a specifc service or set of services. CBOs then structure their organizational offerings around this specifc funding source and provide the necessary ser- vices outlined in grants. CBOs can become siloed ‘CBOs can directly contract for their own services.’ Fee-for-Service CBOs negotiate a payment amount that they will re- ceive for a single event or service. A CBO may contract with a health plan to deliver falls prevention education to patients recently discharged from the hospital. CBOs would then bill the plan for each patient receiving the intervention. Flat Rate CBOs negotiate to be paid a specific amount over a certain period of time. A CBO may contract with a health system to be paid a specific amount for a one-year period, during which they deliver meals to a defined number of homebound older adults. CBOs may then bill the system monthly or quarterly for a pro-rated amount of the total. Population-Based Payment CBOs negotiate a payment based upon outcomes for a specific population. A CBO may negotiate with a health plan to be paid a certain amount per person, per month for care coordination services. The CBO may be asked to ensure certain clinical outcomes or cost-savings. Source: Pacific Business Group on Health, 2017.

around funding streams, making it difficult to have a cohesive set of services. Fortunately, with increased awareness about social determinants’ impact on health outcomes, and the valuable roles that CBOs play in commu- nities, trends show that partnerships between CBOs, providers, and payers are moving from informal, ad hoc arrangements to formal agree- ments that outline service delivery requirements. More than 80 percent of CBOs partnering with health systems create an agreement to address such items as roles and responsibilities of each partner, services covered by each orga- nization, and the duration of the arrangement (Bradley et al., 2016). Just as traditional provider organizations con- tract with health plans, CBOs can directly contract for their own services. Some of the emerging pay- ment methods are summarized in Table 2 (above). √ CBOs have the flexibility to provide any services that they deem valuable, within the constraints of their monthly payment amount. √ As CBOs may have a portion of their payment “at risk” if they do not achieve outcomes or cost-savings, they need to provide adequate time to achieve the desired outcomes. √ CBOs have the ability to negotiate a reimbursement that covers the total cost of each intervention. √ The provider or plan may not be willing to reimburse the total amount, and the CBO would need to find oth- er funding sources to cover the cost difference. CBOs may find that the service costs more than expected, and would need to wait for another contracting period to re-negotiate. √ CBOs are guaranteed a predictable amount of income, and can build capacity to meet the exact requirements of the contract. √ CBOs need accurate cost information to ensure that the flat rate will cover all of the program expenses.

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Fundamentals of Community-Based Managed Care: A Field Guide

relationship, they can explore contracting for services.

How to create successful payment arrangements CBOs and healthcare organizations are increas- ingly receptive to formal agreements around ser­ vice delivery. To sustain programs and solidify the valuable role CBOs play in improving health, funding arrangements must evolve from a depen- dence upon grant funding to robust payment con­ tracts. To achieve that goal, CBOs can beneft from guidance on selecting partners for payment agreements, as well as on how to create contracts. Selecting an organization with which to partner on service delivery is an important foun- dational step in relationship development. The Center for Health Care Strategies, Inc. (2017), highlights attributes of successful partnership, including the following: √ Mission and values alignment; √ Ability to leverage complementary areas of expertise; √ Clear and well-communicated referral process between organizations; and √ Transparent, frequent communications. Once partners have established a trusting

Opportunities for Expansion Abound Healthcare systems contracts offer CBOs myriad opportunities to expand their ability to identify and serve those in need and to garner support for their programs. Health providers and pay- ers are increasingly open to these new fnancial arrangements, and the movement toward value- ‘For a contract to make financial sense, there must be an appropriate patient volume.’ based payment and recognition of the signifcant impacts of social determinants upon health cre- ates an environment conducive to contracting out for CBO services—a process that can be lengthy, but is in many cases feasible. CBOs can beneft from shifting the orga- nizational mindset from outputs to outcomes.

Partnership Components Necessary for Success Partners in Care Foundation (Partners), a Los Angeles–based nonprofit, has extensive experience in direct con- tracts with providers and plans, with between 20 percent and 30 percent of its revenue generated by contracts with providers and payers. When creating contracts, Partners recommends investing substantial up-front effort in defining contract terms—including realistic volume targets, clear workflows for each organization, and an up- front payment component for start-up costs. Partners also stresses that contracts are more likely to be success- ful if they include the following components: Broad service area. Health plans and payers are more likely to contract for services that cover their entire geographic area, including their whole provider network. CBOs will have greater success if they provide services across a wide geography. This may lead to working with other CBOs in their community to provide services. Clear value proposition. CBOs must understand the health system’s needs and demonstrate how their programs can meet these needs. In most cases, this requires collecting program outcomes data and using it to demonstrate program effectiveness. It is also common for a contract to require that a CBO program meet a min- imum return on investment, so understanding and controlling program costs are critical. It is vital for the payer to realize that in order to have a real impact, the value proposition cannot be achieved without sufficient volume. Realistic volume requirements. For a contract to make financial sense, there must be an appropriate patient volume. It is difficult to meet contract terms if there are too few or too many patients; thus it is crucial to use experience to calculate a realistic and reasonable volume. In some of Partners’ recent contracts there were arrangements to provide for a guarantee of minimum volume—this provided a better alignment at all levels for both organizations.

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This requires a concerted effort to collect data that demonstrate the value and effectiveness of their programs, and to use such data to develop contracting arrangements with health systems. Instead of operating separate, stand- alone programs, CBOs can move toward a coor- dinated approach within their organizations to deliver care. New contracting practices will

provide stability to CBOs, allowing them to continue to fulfll their vital roles within their communities. Margie Powers, M.S.W., M.P.H., directs the Medically Complex Patient Program at the Pacific Business Group on Health in San Francisco, California. She can be contacted at mpowers@calquality.org.

References Amarasingham, R. 2016. “The Potential of Shared-savings Mod- els to Support Integrated Health and Social Services for Complex Patients.” Grantee presentation to the Commonwealth Fund via web seminar, August 16, 2016; goo.gl/L9n6fe. Bradley, E. H., et al. 2016. “Varia- tion in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Care, 2000–09.” Health Affairs 35(5): 760–8.

Center for Health Care Strategies, Inc. 2017. “An Inside Look at Part- nerships Between Community- based Organizations and Health Care Providers.” goo.gl/6pZkSY. Retrieved November 14, 2017. Centers for Disease Control and Prevention. 2017. “Social Deter- minants of Health: KnowWhat Affects Health.” goo.gl/p1Cm1L. Retrieved November 20, 2017.

Miller, E., Nath, T., and Line, L. 2017. Working Together Toward Bet- ter Health Outcomes . Final report to the Partnership for Healthy Out- comes. goo.gl/3mh7wU. Retrieved Novembe r 20, 2017.

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Fundamentals of Community-Based Managed Care: A Field Guide

The Value of the Hospital−CBO Partnership in Achieving the Triple Aim By Bonnie Subira

When a health system realized its gaps in knowledge and formed multiple partnerships, it learned the value of tackling the social determinants of health.

I n the world of managed care, much has been written about the drivers of change that hospi- tals face, but less about the importance of part- nering with community-based organizations (CBO) to meet these challenges. The Affordable Care Act led the Centers for Medicare & Medi­ caid Services (CMS) to develop regulatory pro- grams such as Pay-for-Performance (P4P) and its Value-Based Purchasing (VBP) and Readmis- sion Reduction initiatives. These programs’ requirements seek to embed CMS’s concept of value: better health, better care, and lower costs (or, the Triple Aim), and begin to push the evolu- tion from volume-based reimbursement toward alternative payment value-based models. As hospitals explore strategies to address these new regulations, they must consider that effecting better health, better care, and lower costs requires the combined services of health- care and CBO communities. Hospitals and the healthcare community cannot achieve these aims by focusing only on clinical practice.

Concurrently, our country has a fast- growing aging population. The impacts of this demographic trend include seeing cohorts with a signifcantly higher rate of severe chronic health conditions and cognitive impairment; this means older people will have greater functional limitations and require more health and sup- portive services. As an example, the California State Plan on Aging 2017–2021 (2017a; goo.gl/y1xuSX) describes the demographic changes as “an age wave” that will be felt in every aspect of society. The econo­ mic, housing, transportation, health, and social support implications of this phenomenon must also be viewed in the context of the state’s tre- mendous population growth, which continues to challenge its infrastructure planning. Demogra- phers project that California’s population, now nearly 38 million, could by 2050 reach 51 million. At the same time, residents ages 85 and older will have increased 310 percent (California Depart- ment of Aging, 2017b; goo.gl/wBsV68).

abstract Given the impacts of social determinants of health, the goals of the Triple Aim can only be achieved if hospitals are willing to reach out and strengthen partnerships with their local networks of community-based organizations (CBO). Community Memorial Health System has endeavored to do that in forging their partnership with the Camarillo Health Care District, and in forming the Ventura County Hospital to Home Alliance. This article explores how CBOs can complement and enhance the healthcare community’s effort to better manage illness and chronic disease in pursuing the Triple Aim. | key words: Community Memorial Health System, Camarillo Health Care District, Hospital to Home Alliance, Triple Aim

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Where do hospitals begin to meet the daunt- ing mandates imposed by this disruptive demo- graphic, the P4P program, and the Triple Aim? Community Memorial Health System’s (CMHS) journey to fnd an answer has led to the forma- tion of some non-traditional partnerships. How People Became Patients Established in 1902, CMHS is a community- owned nonproft health system serving Ventura County. CMHS operates two hospitals and six- teen community clinics throughout the county and in 2014 established an Accountable Care Organization (ACO). The CMHS journey began with a process of self-examination and a look back to better understand how the healthcare industry, and healthcare delivery, had become so impersonal. Throughout the 1960s, as the Medicare program was being signed into law, 85 percent to 90 per- cent of medical school graduates across the na­ tion were choosing specialty medicine ( What If Post , 2009). Growth in specialized medicine added to signifcant advances in medical science in these years, while access to hospital care in­ creased. Healthcare delivery began to change and with it the unintended consequence of peo- ple becoming “patients.” As care became more specialized within the hospital setting, the person (now “the patient”) became the acute problem for which they received treatment: they were seen as “the heart,” “the gallbladder,” “the hip.” Hospital care became more clinically sophisticated, involv- ing multiple physicians, but at the same time, grew more impersonal. Hospitals were facilities that addressed illness, not wellness, and, in large part, problems, not people. Somewhere along the line, and in an effort to provide better care, the focus shifted almost In an effort to provide better care, the individual receiving care got lost.

exclusively to an emphasis on clinical profciency and technical excellence, while the individual receiving the care got lost. The healthcare indus- try established a boundary such that when a patient had a non-clinical need that could nega- tively impact health status, a common response was “that’s a social issue.” In its extreme, patients were categorized as non-compliant and judged unwilling to follow medical instruction, when in many cases the issue was the person’s unas- sessed or unmet non-clinical need. This narrow clinical focus further impersonalized care and fostered silos in the healthcare industry. Today, although more than 95 percent of healthcare dollars is spent on direct medical ser- vices, as much as 70 percent of health outcomes can be attributed to the influence of non-clinical factors (Organisation for Economic Co-operation and Development, 2009). In the United States, the disparity between healthcare spending and social service spending is notable; America scores almost last among developed countries. Answers Lie Beyond Hospital Walls While continued clinical quality improvement is an essential component in achieving the Triple Aim, it is not enough on its own. Medical treat- ment alone does not create nor sustain good health. Thus, the starting point for CMHS was to expand the focus from the patient to the person and to consider the non-clinical or social deter- minants of health. CMHS wondered how hospitals managed their accountability for health outcomes and costs beyond their scope of services and outside the hospital walls. They reached the conclusion that a hospital could not do it alone, but required improved partnerships with CBOs. Many health- care colleagues report that they have formed such partnerships and offer as evidence long lists of community resources. While giving patients a list of phone numbers, dialing those numbers, setting up appointments, or providing “warm hand-offs” does demonstrate a hospital’s abil- ity to identify CBO resources and make referrals,

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Fundamentals of Community-Based Managed Care: A Field Guide

care transitions services to our Medicare patients who were being discharged (as part of the CMS grant-funded Community Care Transitions Program), our response was a guarded yes. How could a hospital turn down free help to strengthen care transitions? Frankly, we had concerns: What did this social service agency, The Camarillo Health Care Dis- trict, know about chronically ill Medicare patients? In retro- spect, we now know they knew signifcantly more than health- care providers had given them

Table 1. Incorporating Social Service Spending

credit for. Once our hospital realized the District was not there to provide clinical care, we began to see the value they brought in offering a broader view of a person’s needs and the services neces- sary to address them. The District has been instrumental in help- ing to identify the unmet community needs that drive poor health outcomes and increased costs. In our partnership thus far we have joined forces to better address family caregivers’ needs and to provide early intervention against cogni- tive impairment and dementia—conditions that affect health status and thus increase health- care costs. Enter the Second Partnership While CMHS began a relationship with the Dis- trict, we invested in another new partnership in pursuit of the Triple Aim. For some time, CMHS had been meeting with local home health pro- viders and skilled nursing facilities in an effort to strengthen transitions from the hospital, reduce unnecessary readmissions, and better manage chronic disease in the community. But we were not making the progress we had anticipated. In concert with the regional CMS quality improve- ment organization, the Health Services Advisory Group, we reached out to other area hospitals

there are distinct differences between main- taining a CBO referral list and cultivating a CBO partner. Partnership is characterized by mutual coop- eration and responsibility in the achievement of a specifed goal. Over the past fve years, CMHS has been fortunate to have formed such a part- nership with the Camarillo Health Care District (the District). ‘How could a hospital turn down free help to strengthen care transitions?’ The District is a local public agency estab- lished in 1969 and was created to provide a range of community-based programs and services designed to promote health and wellness in the community and at home. It offers a wide array of services, but specializes in programs that support the independence and dignity of older adults and people with disabilities through such programs as evidence-based health promotions services, falls mitigation, adult daycare, home- delivered meals, caregiver support services, care transitions, case management, and many others. In 2012, the District, while known to CMHS, was severely underused. When District staff walked into our hospital and offered to provide

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and a large managed care organization to form a coalition to work with the District. The District was an integral part of the coalition, which has become known as the Ventura County Hospital to Home Alliance (Alliance). In its present form, the Alliance comprises ten home health agencies and seven skilled nursing facilities, as well as the District and CMHS. The larger group did not immediately embrace the idea of including the District as a CBO participant in a predominantly clinical CMHS’s ability to reach beyond the hospital walls has reaped many early benefits. coalition. Initially, the clinical providers did not see the value of the CBO with respect to disease management, or how it might contribute to read- mission reduction and care continuum quality. Several home health agencies were threatened by the District’s presence, believing it to be a direct competitor for their services. This scenario afforded the Alliance several opportunities for improvement. First, it needed to create equal understanding between part- ners about the mandates inherent in healthcare reform and the concept underlying the Triple Aim. Second, it needed to acknowledge the fact that Alliance partners generally work in iso- lation and are largely siloed by sector. As the group confronted the challenges of moving from business as usual to a value-based environment, it was able to see that many of the barriers it faced in caring for patients were social, not clinical. When Alliance members realized that social issues did not release them from the responsi- bility for their patients’ improved healthcare outcomes, they made signifcant progress on partnership goals. The Alliance membership began to understand the power of partnering with the District, a collaboration that could best address patients’ social needs.

As was the case with CMHS, each Alliance member was relatively knowledgeable about community resources, but none had explored the value of community partners. Expanding the continuum of care to include the District allowed the group to engage in multiple process improve- ment projects that actively identifed the social issues interfering with patient transitions and resulted in improved chronic disease manage- ment in the community. Each Alliance member now makes use of the District’s robust programing in the areas of caregiver support, cognitive impairment, and chronic disease management by proactively involving the District before patients leave their care setting. As a result, the District now has earlier access to patients and families to help them prepare for care transition and return to the community. Because they are working across the Alliance continuum, the District plays a key role in care coordination and has helped to improve communication and integration of the Alliance’s services. Apart from direct person care, the District has taught CMHS, as well as the Alliance mem- bership, about the world of long-term services and supports (LTSS) that serves older adults and people with disabilities. Our healthcare commu- nity sorely lacked awareness about the breadth and depth of programming and advocacy that occurs in promoting health maintenance and wellness for older adults—a knowledge gap that directly contributed to community pro- viders operating in silos. So while the District learns the language and acronyms of healthcare, CMHS and the Alliance are learning the lan- guage of the LTSS community: how they operate on national, state, and local levels, and the pro- grams and work being done to beneft the popu- lations we all serve. The District’s participation in the Alliance has proven not only how much better we are together, but also that this part- nership is essential for meeting the mandates of providing better health and better care and low- ering costs.

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Fundamentals of Community-Based Managed Care: A Field Guide

The CMHS−District partnership has yielded powerful tools for achieving the Triple Aim. We look forward to building this relationship— and cultivating others—in order to provide the most effective and respectful care to the people we serve. Bonnie Subira, M.S.W., is the former director of Case Management, Social Service and Palliative Care programs for Community Memorial Health System in Ventura, California. She now serves as the Health System’s project manager for Population Health Programs.

Conclusion: We Are Better Together! CMHS’s ability to reach beyond the hospital walls has reaped many early benefts. We have gained access to expertise, services, and programs that we cannot provide; we have a better understand- ing of caregivers’ needs; we have access to care mangement programming for dementia patients and their families, along with improved access to other CBOs and social programs. As well, CHMS has a new orientation toward the LTSS commu- nity; better services integration; reciprocal and ongoing communication; and decreased siloed activities and services duplication.

References California Department of Aging. 2017a. California State Plan on Aging 2017–2021. goo.gl/y1xuSX. Retrieved October 17, 2017. California Department of Aging. 2017b. California State Plan on Aging 2013–2017 . goo.gl/wBsV68 . Retrieved October 17, 2017.

Organisation for Economic Co- operation and Development (OECD). 2009. OECD Health Data 2009—Comparing Health Statis- tics Across OECD Countries . goo.gl/tuFQ4h. Retrieved October 23, 2017.

What If Post . 2009. “History of Health Care.” December 20. goo.gl/J8LXPi. Retrieved October 17, 2017.

Volume 42  . Number 1 | 13

GENERATIONS – Journal of the American Society on Aging

CareMore Health Tackles the Unmet Challenges of the Aging Population By Sachin H. Jain

A high-touch, team-based clinical model addresses everything from high blood pressure to loneliness.

C areMore Health originated twenty-fve years ago as a medical group, and employs a proac- tive, high-touch clinical model focused on pre- vention and education. Founded and led by physicians, the organization is a care delivery system for Medicare and Medicaid benefciaries that uses an integrated delivery model to provide an individually tailored holistic approach, includ- ing chronic disease management, through highly coordinated care. By addressing patients’ medi- cal, social, and personal health needs, the re- sulting clinical outcomes rank well above the national average. The CareMore Health delivery system was created to care for the most frail, costly, and often underserved patients by proactively identi- fying and managing specifc health needs. Many older adults suffer from chronic disease, and ap­ proximately 44 percent of CareMore’s patients are enrolled in Medicare Advantage Special

Needs Plans (SNP) tailored to treat specifc and often chronic health conditions such as diabetes, heart disease, and respiratory ailments. Other SNPs address health and economic status, such as dual eligibility for both Medicare and Medi­ caid programs (D-SNP) and those patients requiring institutional care. While also addressing social and psycho- logical health needs, CareMore Health provides specialized programs to help older adults bet- ter manage health conditions such as congestive heart failure, chronic kidney disease, end-stage renal disease, chronic obstructive pulmonary dis- ease, diabetes, and more. To provide proactive care and better care management of such condi- tions, high-risk patients are identifed early on, and CareMore staff communicate with them often (depending upon level of need), via telephone and in-person interactions at a CareMore Care Center, to ensure they are maintaining their health.

abstract Older adults and others with complex and high-risk medical conditions often lack access to the coordinated care they need to properly manage their chronic issues, resulting in hospitalizations and more spending on treatment. CareMore Health, an integrated values-based care delivery system that provides care to Medicare and Medicaid beneficiaries, focuses on caring for the frailest populations by harnessing the power of teamwork to treat its patients’ medical, social, and personal health needs. By investing in prevention, early intervention, education, and partnerships with community-based organizations, CareMore Health achieves fewer hospitalizations, bed stays, and overall better health outcomes for patients compared to beneficiaries covered under fee-for-service Medicare. | key words: CareMore Health, Care Center, integrated care, Togetherness Program

14 | Spring 2018

Fundamentals of Community-Based Managed Care: A Field Guide

behavioral health clinicians, pharmacists, Nifty after Fifty ftness programs (a CareMore part- ner), and other clinical specialties. CareMore Health currently operates 42 Care Centers across California, Arizona, Nevada, Virginia, Tennessee, Georgia, Iowa, and Connecticut. Each new CareMore patient undergoes an extensive health assessment (or “Healthy Start” appointment) at the Care Center to cre- ate a personalized care management plan. At the appointment, a clinician performs an in- depth interview and exam to proactively iden- tify chronic diseases and other health needs. Based on specifc health needs, the patient is then placed in a high-touch, disease-specifc program . The clinical assessment is designed to involve patients and family members in mak- ing shared decisions about their health plans. The Healthy Start appointment also allows CareMore clinicians to identify other medi- cal concerns, including behavioral and men- tal health needs (e.g., clinicians query patients to determine their social activity and ask them

A Cornerstone of Care The cornerstone of CareMore’s model is the comprehensive Care Center, where patients receive direct care and attention fromCareMore- employed clinicians. Care Centers are located in the community and house chronic disease− management programs, post−acute care follow- up for people who have been discharged from Patients with complex medical needs cannot be managed solely by one clinician. the hospital, and other services to manage high- risk and high-need patients. The Care Center and clinical team act as an extension of the primary care physician’s office. In addition to chronic disease support and post-hospitalization care, integrated services such as dental care, optometry, and drug consultation are offered to maximize visits to the Care Center. Patients have access to case managers, social workers,

Volume 42  . Number 1 | 15

GENERATIONS – Journal of the American Society on Aging

to rate their depression level). CareMore con- siders physical activity to be the ffth vital sign and prescribes exercise into care management plans for those with chronic medical conditions. Patients’ primary care providers are kept in the loop through regular phone, email, text, and fax communications. One clinician alone cannot support individ- uals with complex medical needs; thus, Care- More’s team-based approach harnesses a group of healthcare workers to address patients’ over- all health needs, working together diligently to keep patients out of the hospital using high- touch care and consistent communication. Using this team-based care approach, the Care Center team works together to coordinate and integrate needed care on the spot, and under one roof, to maximize each visit. If patients are admitted to the hospital, Care- More “extensivists” (physician hospitalists who care for older adults in outpatient and skilled nursing facilities) monitor patients during and after the hospital stay. Extensivists ensure that CareMore patients receive holistic health man- agement by working closely with primary care physicians, specialists, and the Care Center team so that all areas of health are considered when deciding treatment options. Technology helps reduce hospitalizations In a case study published by The Common- wealth Fund, our most recent analysis shows that compared to benefciaries covered under fee-for-service Medicare, CareMore has been successful in reducing hospitalizations by 20 percent (Hostetter, Klein, and McCarthy, 2017). CareMore achieves these results through employing the best clinicians, consistent com- munication with patients, using technology to track health conditions, and providing early intervention through remote-monitoring de­ More than 500 patients are actively enrolled in the Togetherness Program.

vices. CareMore clinicians use these devices to monitor patients who are high risk; this helps eliminate unnecessary physician office visits. For example, monitoring the weight of patients with congestive heart failure can provide early notifcation of decompensated heart failure, or worsening signs and symptoms of heart failure. CareMore provides wireless weight scales to patients and weight gain alerts are sent to Care- More nurse practitioners, who can intervene and prevent decompensated heart failure. CareMore also provides in-home hypertension/blood pres- sure monitoring, which can be tracked remotely by CareMore clinicians. The use of remote moni- toring has proved effective in treating symptoms before they escalate, thus reducing patient hospi- talizations. Older adults’ medical needs can be complex and often vary considerably. CareMore Health has developed a wide array of programs and services to meet its patients’ specifc health and social needs. A high percentage of these are created in response to direct feedback from patients about their needs. Services like foot care, remote moni- toring, transportation, and programs like brain health, dental care, and our Togetherness Pro- gram that addresses loneliness and isolation. Combating loneliness and isolation Retirement, the loss of friends or family, people moving away, or living alone all can contribute to older adults feeling alone and or isolated (Cotten, Anderson, and McCullough, 2013). More than 43 percent of people ages 65 and older report that loneliness has affected them (Perissinotto, Cenzer, and Covinsky, 2012). Due to its complexities and masked symp- toms, loneliness often is invisible, but has sig- nifcant health consequences: loneliness can be as damaging to health as smoking ffteen ciga- rettes a day, and may increase a person’s risk of mortality by 45 percent—more than air pollution Programs Address Special Health and Social Needs

16 | Spring 2018

Fundamentals of Community-Based Managed Care: A Field Guide

(6 percent), obesity (23 percent), and excessive alcohol use (37 percent) (Perissinotto, Cenzer, and Covinsky, 2012; Holt-Lunstad, Smith, and Layton, 2010). It also is a risk factor for numer- ous serious medical conditions, including cog- nitive decline, the progression of Alzheimer’s disease, and recurrent stroke (Cacioppo et al., 2015). Despite the fact that loneliness is a com- mon emotional distress syndrome with a high- risk factor for early mortality and the cause of a broad spectrum of physical health and psychiat- ric issues, it receives scant attention in medical training and in the healthcare setting. CareMore is committed to going beyond traditional care solutions to tackle this issue through its Togeth- erness Program. The Togetherness Program is a frst-of-its- kind clinical program designed to address lone- liness and isolation. Launched in 2017, initial efforts focused on building personal connections with at-risk patients through consistent phone outreach. These calls build relationships, provide constant and positive engagement, support indi- vidual healthcare needs, and foster connections to community organizations and resources. Through these calls, CareMore tailors and expands its clinical support based on what patients need the most—whether it is connect- ing with disease management programs oper- ated out of the Care Centers; accessing physical activity at Nifty after Fifty ftness programs or other community resources; or providing hear- ing aid support. Since the launch of the Togeth- erness program CareMore has identifed 2,000 lonely older adults through screenings; and enrolled more than 500 in an intensive inter- vention that includes weekly phone calls, home visits, and encouragement and connection to community-based programs. Community-based organizations (CBO) play a vital role in address- accessing care easier.’

ing loneliness and isolation and CareMore’s part- nership with CBOs is essential to the success of the program. One community organization, Senior Center Without Walls, is a virtual com- munity where older adults participate in support groups, activities, and other social gatherings via phone or online from their homes. This CBO has helped CareMore to connect patients who may be geographically isolated from society and can- not drive to a nearby senior center. CareMore also works with the Alzheimer’s Association of Greater Los Angeles to provide much needed caregiver education and respite care to the care- givers of those suffering from dementia. ally miss or delay receiving non-emergency care due to transportation challenges (National Conference of State Legislatures, 2016). Lack of access to consistent, affordable transportation can mean older adults miss medical appoint- ments, which ultimately affects their access to necessary care. Achieving greater clinical care is possible only if older adults can get to it, so to improve the transportation experience in 2016, CareMore formed an alliance with the ride-sharing com- pany Lyft. Early results of the pilot program are promising, and showed that wait times had been reduced by 30 percent, according to the study, Non-emergency Medical Transportation: Deliv- ering Care in the Era of Lyft and Uber (Powers, Rinefort, and Jain, 2016). The Future of CareMore Health What started as a medical group caring for older adults in California has become a healthcare deliv- ery system that has expanded to provide care for more than 150,000Medicare andMedicaid ben- efciaries across California, Nevada, Arizona, Vir- ginia, Tennessee, Iowa, Georgia, and Connecticut. Over the years, CareMore’s goal has remained the same—to provide high-touch affordable care to those who need it most. CareMore’s commit‘Our partnership with Lyft makes Providing affordable transportation It is estimated that 3.6 million Americans annu-

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