A Primer on Managed Care: Multiple Chronic Conditions

Kaiser); two Cal MediConnect (dual eligible) plans (L.A. Care, Health Net); and one Account- able Care Organization (ACO) (UCLA Health). The services involved are varied, but include the following: health risk assessments; adult day health eligibility determinations; care tran- sitions from hospital or skilled nursing facility back to home; Partners’ HomeMeds program and in-home psychosocial, environmental, cog- nitive, and functional assessments; short- and long-term-care/service coordination; and self- management support. These interventions all address individual- level social and behavioral determinants of ‘These interventions all address individual-level social and behavioral determinants of health.’ health, and include caregiver support, provi- sion of nutritious meals, knowledge for self-care, medication adherence support, transportation, and access to benefits. Examples of Working Partnerships UCLA Health is the partner with which Partners has the longest and deepest relationship—it has lasted for more than seven years. Relationships built over decades resulted in UCLA Health engaging Partners to support its strategic plan on community services. In addition, Partners’ CEO (co-author June Simmons) was invited to participate in UCLA Health’s primary care redesign team. Together with UCLA Health, Partners applied for and won a Centers for Medicare &Medicaid Services (CMS) Community-based Care Transi- tions Program (CCTP) contract to reduce fee-for- service Medicare readmissions. The process of preparing that application, which included an in- depth root-cause analysis of readmissions, built multi-level relationships between UCLA’s and Partners’ staff and leaders, from the chief medical officer to primary care case managers.

Operating the program further cemented relationships as Partners’ staff worked to refine referral processes and coordinate care with UCLA social workers, nurses, pharmacists, and primary care physicians. The success of the CCTP led to a contract with the medical group to address readmissions in UCLA Health’s Medi- care Advantage and ACO populations. Measuring Impacts and Analyzing Outcomes UCLA has been an excellent partner, especially in terms of how it has measured the impact of the collaboration. Two post-acute interventions have been used and the results of both have been outstanding. The first was the CMS-funded CCTP, through which Partners and UCLA worked together from 2013 to 2017. According to CMS (Econometrica, Inc., and Mathematica, 2017), “30-day post-dis- charge Part A and Part B expenditures were 17.30 percent (p<0.01) lower among participants than for matched comparisons. After accounting for this site’s average PEDR [per-eligible discharge rate], this translated into lower net differences in Medicare Part A and Part B expenditures of $10,771,936 (p<0.01) between participants and matched comparisons.” A recent UCLA study (pending publication) did a propensity score matched analysis and found significant improvements in 30-, 60-, and 90-day readmissions and emergency department use. The interventions were the Coleman Care Transitions Intervention (a home-based health coaching model;, and the Rush University Medical Center’s The Bridge Model (telephonic social work; y9tvgdl4), plus Partner’s medication safety inter- vention, HomeMeds. HomeMeds involves a comprehensive in- home inventory of all medications, including over-the-counter medications and supplements; use of a computerized, evidence-based risk- screening tool; and pharmacist review and rec- ommendations to patient and prescribers (AHRQ Innovation Exchange, 2010), and uses a UCLA

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