GENERATIONS – Journal of the American Society on Aging

most health plans were eager to initiate care manager training. Project staff viewed train- ing as a prerequisite for system change, but noted that it needed to be coupled with advo- cacy and technical assistance. Health plans are large, highly regulated organizations that often have several lines of business and operate across county and state lines. Consequently, system changes required thorough analysis and took time to implement. Project partners discussed the iterative nature of their advocacy as crucial to effect change.

“What would be nice, in [an] ideal techni- cal world, would be if someone answered the screening question that’s in the health risk assessment with the answer that identifies that there could be a cognitive disorder, [and] that it would automatically show up in the system for the case manager to ask them to do the screen- ing. [Ideally], I think . . . you would just want it to automatically happen, and leave less to the human mind to remember . . . to do that extra step,” said a CMC plan partner. One plan, in discussing how mining their data helped encourage systems change and acknowledging that getting the data into their IT system took time, noted: “We didn’t have a good grasp on how many of our members poten- tially had dementia. Once we identified the scope of the population, we realized . . . we needed to implement several process changes, which also involved changes to IT systems. Plans were set in place, but those changes . . . [took] more time than we had hoped [they would].” Medicare beneficiaries living with dementia face multiple challenges to receiving the care they need in HCBS settings. Historically, unless they also have Medicaid, they have limited or no access to publicly funded long-term-care ser- vices offered outside of nursing homes. Programs that blend Medicare and Medicaid, like the duals demonstration, PACE programs, and health homes offer opportunities to improve care for this population: they rely upon greater care coor- dination; they recognize the importance of the family caregiver role; and they create an align- ment in the financial incentives to provide better care at a lower cost. As with the duals demonstration, newer models of care that encourage care coordina- tion and HCBS use present opportunities for the aging network and other HCBS providers to partner with health plans to improve care for people living with dementia. Promising practices Improving Healthcare for People with Dementia

‘Health plan and state staff turnover made maintaining momentum difficult.’

Another project partner noted: “Change is slow. You have to be persistent, and you have to be present . . . . If you do this for a year and think you’re going to make big change happen in one of these systems, you’ll be very frustrated. We had been working with some of the plans for four and a half years with changes in their cor- porate structure and changes in staffing turn- over and in federal and state policy.” In most cases, technical assistance and advo- cacy with health plan decision-makers has been key to them adopting systems changes. For example, use of a fax referral tool, ALZ Direct Connect, was taught in all trainings, but the project found that training alone was insufficient to generate referrals. Only after extensive out- reach to the plans were the project partners able to identify and negotiate more systematic adop- tion of the fax referral form; still, referrals from the plan remain low, indicating the need for fur- ther technical assistance and advocacy. Identifying opportunities to “bake in” systems change . Project partners and CMC plans both noted that the best way to ensure sys- tems change was to “bake in” changes to existing electronic medical records and care manage- ment systems and protocols.

76 | Spring 2019

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