Care Models for High-Need, High-Cost Patients

In 2014, Vermont encouraged the state’s largest payers — Medicare, Medicaid, and Blue Cross and Blue Shield of Vermont — to move more quickly from fee-for-service to risk-based contracting. The concept appealed to OneCare Vermont, a large accountable care organization (ACO) that had engaged more than half the state’s physicians and nearly all its hospitals in its network but had struggled to earn savings in its previous contracts with insurers. This case study examines OneCare’s community-driven approach to care coordination, which it piloted in 2017 among a subset (around 29,000) of the state’s Medicaid beneficiaries.

This case study focuses on the development and effects of the Advanced Illness Management program at Sutter Health in Northern California, where nurses and social workers engage terminally ill patients, elicit and document their goals, and support them as they navigate their physical and emotional challenges.

As a Medicare Advantage plan that also provides medical care to its members, CareMore partners with primary care physicians to identify and refer high-risk patients who would benefit from support at its Care Centers, where multidisciplinary care teams manage patients’ needs holistically and oversee acute care.

At the One Care: MassHealth plus Medicare program at Commonwealth Care Alliance, interprofessional care teams provide integrated, high-touch care to patients in homes, primary care practices, and community settings, using flexible benefits that cover services not traditionally reimbursed by Medicare or Medicaid.

In the Care Management Plus program at Intermountain Healthcare in Utah, a care manager, embedded in a primary care practice and supported by specialized information technology tools, works with patients who have complex needs to develop and implement plans for care, coaches patients and their caregivers, and more.

In the Guided Care model, specially trained nurses create care plans, educate and support high-need patients and their caregivers, and coordinate care among providers, using formal assessment and planning tools to set priorities for stabilizing health and achieving patients’ goals.

In partnership with social service agencies and nonprofits, Hennepin Health, a Medicaid accountable care organization, proactively identifies members most at risk and provides them with care coordination and social support.

On Lok Senior Health Services, a Program of All-Inclusive Care for the Elderly (PACE) organization, provides comprehensive medical and social services delivered in community day centers and people’s homes.

Presbyterian Healthcare Services in Albuquerque, New Mexico, a large integrated delivery system, offers adult patients who are sick enough to be hospitalized but stable enough to be treated at home that option, and more than 92 percent take it.