To locate, stratify and engage dual eligibles, Health Care Services Corporation (HCSC) takes a creative approach, employing everything from home visits to 'street case management' to coordinate care for Medicare-Medicaid beneficiaries.
Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population describes HCSC's innovative tactics to engage this largely older adult and disabled population in population health management with support from a range of community partners and services.
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In this 25-page report, Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation, details HCSC's care coordination model for the dually eligible and some early program impacts, as well as lessons gleaned from 12 years of work with other plans serving duals.
From a kickoff health risk assessment (HRA) to risk-based care and service planning, Ms. Faulhaber describes how HCSC accomplishes the following:
- Stratifies, locates and engages dual eligible beneficiaries into care coordination efforts;
- Employs either a nurse-led or social worker-led care coordination strategy based on the unique needs of the population served;
- Supplements its own in-house care coordination resources with community-based services such as promotoras and tribal government;
- Applies 'street case management' to engage the homeless population;
- Employs unique models to serve the distinctly different needs of dual eligibles with physical or developmental disabilities;
- Integrates medical and behavioral health approaches for duals with serious mental illnesses; and
- Overcomes the roadblocks it has encountered in the dual eligible market.
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P.S. -- You may also be interested in these resources on dual eligibles: