A Primer on Managed Care: Multiple Chronic Conditions

(Boustani, Alder, and Solid, 2018) to identify and implement evidence-based solutions for manag- ing ADRD. The model’s minimum specifications were patient and unpaid caregiver education and support, regular biopsychosocial needs assess- ment, prevention and treatment of comorbid conditions, medication management, and care coordination among clinical providers and com- munity resources. During SECBCI’s decade-plus existence, we have witnessed first-hand how these specifi- cations allow for more personalized and more effective individual and whole population care. A key factor in the SECBCI’s success is that our care for ADRD extends beyond that which is given in the primary care setting, acknowledg- The model has improved ADRD patient care because of its wider view of care for a defined population. ing and addressing the influence of social deter- minants in the health and wellness of those with ADRD and their unpaid caregivers. In short, the model has improved care for people with ADRD because of its wider view of care for a defined population. To expand these lessons to other populations, Eskenazi Health leadership recently convened an interdisciplinary team to discuss elements of a successful population health management model with the following four priorities: an accountable health community; an interdisciplinary, diverse, and scalable workforce; evidence-based care pro- tocols; and a data warehouse with a comprehen- sive performance feedback loop at the individual and the population levels. Definitions of these elements and how they work together are as follows: The accountable health community is a fully integrated (i.e., owned by the same entity or connected through a joint venture) system of community-based and healthcare delivery orga- nizations in a defined community that informs

the size and scope of subsequent elements needed to fully support its members. The interdisciplinary, diverse, and scal- able workforce is a team-based approach involving providers and community partners outside the healthcare system. In addition to pri- mary and specialty care clinicians, other criti- cal teammembers include counselors and health coaches, care coordinators, community health workers and resource navigators, administra- tors, business developers, and researchers. The diverse skill sets and collaboration with commu- nity partners emphasize the importance of social determinants of health. It is a more affordable, scalable, and sustainable approach than clini- cian-only models. These partnerships between health systems and community services reduce costs by reducing duplicative or unnecessary care, or connecting people with appropriate community services, which may reduce the need for subsequent interventions or hospitalizations, without sacrificing quality. Evidence-based care protocols ensure the highest quality of care and incorporate multiple determinants of health, including those related to cognitive, physical, medical, genetics, and behavior, as well as non-clinical aspects related to communication and documentation, and social circumstances. The data warehouse with a comprehen- sive performance feedback loop requires sev- eral characteristics. The first is a reliable and valid sensor, i.e., a means for collecting, monitor- ing, and alerting about modifiable (e.g., substance abuse, weight, employment) and non-modifiable (e.g., age, sex, race) biopsychosocial informa- tion about each population member. The sensor is a set of algorithms that automatically iden- tifies when certain events occur (e.g., a health encounter) or when there are certain combi- nations of data elements indicating that a per- son may require additional attention or may be at increased risk for other conditions or adverse events. For example, if a person living alone is diagnosed with cognitive impairment and

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