GENERATIONS – Journal of the American Society on Aging

Health MYMEDS ( phar- macist to review and make recommendations to improve the medication regimen. Allowing for a choice of a home visit or telephonic interven- tion substantially increased the programs’ geo- graphic reach and overall uptake. ‘UCLA has been an excellent partner in measuring the impact of the collaboration.’ The second, HomeMeds Plus ( y9sfovtj) , includes HomeMeds, plus an in-home psychosocial, fall-risk, and functional assess- ment with thirty or more days of follow through to identify and address unmet behavioral health and socioeconomic needs. The intervention is delivered by at least a bachelor’s-degree-level human services professional, a social worker or health coach, and a pharmacist, who addresses medication issues. According to UCLA, the post-acute Home­ MedsPlus intervention, which included UCLA’s MYMEDS pharmacists, decreased the overall readmission rate for the total high-risk popula- tion from 31.3 percent to 26.9 percent (net of the 1.4 percent decrease in readmissions experienced by the low-risk population). Compared to high- risk patients who did not receive the interven- tion, UCLAHealth found that HomeMeds Plus achieved a dramatic 66 percent relative decrease in the readmission rate—from 31.3 percent to 10.6 percent. The population consisted of UCLAmedi- cal group’s ACO andMedicare Advantage plan members and primary care patients. This paid contract involves about 300 patients a year. Partners’ other contracts also are excellent examples for CBO−healthcare partnerships, serving thousands of individuals each year with effective evidence-based care coordination and self-management models. These contracts con- tinue to grow and prosper after three or more years, and even incorporate reimbursement increases to address geographic issues for our

Partners at Home Network, related to staff trav- eling extreme distances in some of the largest counties in the United States. Thus far, however, only UCLA has shared its outcomes. Lack of outcomes data from oth- erwise thriving healthcare contracts is a widely acknowledged barrier for CBOs in this new col- laborative model. Typically, this is because there has been so much change in the informa- tion technology and security requirements for healthcare entities that their technical depart- ments are unable to meet the demand for data reports beyond those mandated for regulatory or accreditation compliance. Moving Forward Sustainably Building on these successes, Partners contin- ues pursuing new contracted relationships with other physician groups, health systems, and managed care organizations, under both Medicaid and Medicare payment. There is new federal flexibility to use Medicare Advantage revenue to address social determinants of health and growing success of some ACO and bundled payment models, and managed long-term-care services and supports for dual eligibles. These Partners continues pursuing new contracted relationships with physician groups, health systems, and MCOs. and the new broadening of Medicare fee-for-ser- vice physician billing codes all present opportu- nities for healthcare entities to use new revenue streams to pay for these powerful interventions. The W.M. Keck Foundation, recognizing the promise of the changing care environment, has provided Partners in Care with a major grant to support model development. The work focuses on the use of expanded Chronic Care Manage- ment Medicare physician billing codes to sup- port integration of medical and social services for people with chronic illnesses.

34 | Spring 2019

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