A Primer on Managed Care: Multiple Chronic Conditions

dementia care managers. Their training focused more deeply on clinical aspects of dementia care, taught attendees how to administer a validated caregiver assessment tool, shared resources for managing common care situations and chal- lenging behavioral symptoms, and emphasized HCBS available through local Alzheimer’s orga- nizations and other providers. All training mate- rials are available on the Alzheimer’s LA website (Alzheimer’s Los Angeles, 2018). This project also used an innovative, proactive fax referral tool called ALZ Direct Connect, where members with dementia and their fami- lies consented, at the time of the care manager visit, to have the local Alzheimer’s organiza- tion contact them with information about sup- ports and services. Alzheimer’s organizations provided care counseling, support groups, and caregiver education, as well as referrals to com- munity services such as free food pantries, renters assistance, and free legal and financial planning organizations. An independent evaluation of the Dementia CMC Project was conducted by the University of California, San Francisco, Institute for Health and Aging. Key lessons learned from interviews with project partners and health plans are described as follows: Variations in plan structures and cultures meant tailored collaboration . CMC health plans had vastly different care management systems, which reflected the size of the popu- lations they served, the way in which they struc- tured and delegated their services, their degree of integration, and whether they were public or private plans. Based on the size of their member- ship, their internal resources, and the capacities of provider groups, plans retained or delegated out all or some of their care management tasks Support services through local Alzheimer’s organizations Lessons Learned from the Dementia CMC Project

to provider groups or contracted entities. Edu- cation levels and experience with dementia also varied greatly among care managers and across settings. To effectively work with each health plan, project staff had to learn how the plans were structured and understand their culture for communication and change. Health plan and state staff turnover made maintaining momentum difficult . High turn- over in the plans and at the state’s Medicaid agency made it difficult to maintain momentum to make systems changes or to organize trainings. Staff often transitioned between health plans during the project period. Said one project part- ner, “ . . . what is challenging is there [has] been turnover, so relationships will be built and then someone leaves a health plan or leaves a partic- ular position . . . we’ve . . . found that sometimes they go to another health plan so we’re again able to leverage the relationship that [was] already built. And that can actually be very helpful.” In other cases, turnover meant the project would slow down or stop, and project staff would have to start anew in building relationships and gaining buy-in to pursue systems changes. High staff turnover also posed challenges in train- ing dementia care specialists because the train- ings are resource-intensive. Online training was explored as a potential solution, but such con- tent is less comprehensive and plans have shown resistance to paying for online training. Change takes time . Implementation of the Dementia CMC Project ran parallel to the rollout of the CMC pilot. While project staff were able to identify champions within the health plans who valued the project, competing needs and priori- ties, especially in the beginning of CMC, made systems change slow. Until health plans made headway on the implementation of the over- arching CMC pilot, they were unable to focus on dementia-specific systems change. This created a delay in rolling out project activities. Care manager training was valuable, but insufficient to create change. Despite the slow implementation of system-change indicators,

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