Senior Care Options at Commonwealth Care Alliance

Commonwealth Care Alliance
Boston, MA

The Problem
Commonwealth Care Alliance, which functions both as part capitated health plan and part provider, developed a Senior Care Options plan for low-income, dually eligible beneficiaries. Analysis in Massachusetts found that primary care for vulnerable and complex populations was inadequate, discontinuous and unengaged with the patients they were meant to serve.

The Solution
Through the Senior Care Options plan, enrollees were provided with a primary care team made up of a physician, nurse practitioner and geriatric specialist who work out of the beneficiary's primary care clinic. They created a new system of multidisciplinary primary care that included the following components: (1) Comprehensive assessments instead of medical histories; (2) Individualized care plans with behavioral health integrated into primary care services; (3)Team trained to go beyond medical services to address poverty alleviation issues; (4)Capacity for home visits and transfer of clinical decision to the home or other settings of care; (5)Team approach with nurse, nurse practitioner, behavioral health, social worker and primary care physician; (6) Fully organized hospital and institutional network centered around primary care team.

First started as a demonstration program, Commonwealth Care Alliance relies on a risk-adjusted premium paid separately from both Medicare and Medicaid. Providing primary care themselves, they contract at agreed-upon rates (typically Medicare reimbursement) for specialty and inpatient care.

The Result
Even with a more complex population, hospital utilization is significantly lower for both nursing home-certifiable and ambulatory-certifiable Commonwealth Care Alliance beneficiaries (1,634 and 511 hospital days per 1000 population respectively) as compared with traditional Medicare fee-for-service beneficiaries (2,620 risk adjusted hospital days per 1,000 population). For Commonwealth Care Alliance nursing home-certifiable enrolled patients living in the community, 46% fewer patients became long-term nursing home residents. These are signs of both increased quality and long-term cost reduction.

This case study was originally featured in the HPOE guide: 'Caring for Vulnerable Populations,' published September, 2012.