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Medicare Advantage (MA) plans are evolving to address their growing market—10,000 baby boomers are now retiring every day, and Medicare Advantage health plans are set to become 50% of the Medicare market by 2025—increasing programs for care management and bringing services to the home to improve care and reduce utilization in their high-risk members.

Savvy MA plans are re-evaluating their care management strategy, especially for high-cost, high-risk seniors with multiple chronic conditions, focusing on three main principles:

• Shifting from episodic to holistic care models
• Bringing care to the home
• Expanding the use of technology

Shifting the Service Model from Episodic to Holistic Care

Until recently, most MA plans deployed episodic care management solutions such as post-acute care or condition-specific programs such as diabetes or cardiac programs. The member experience is limited to the specific program, often missing other related contributors to health conditions and creating a fragmented care experience.

As the market is evolving, health plans are recognizing the value of comprehensive, holistic care especially for members with multiple chronic conditions. A provider-led multi-disciplinary team which includes nurses, social workers, and patient educators work together to create and execute a personalized care program. This approach eliminates care fragmentation by delivering ongoing, longitudinal care. These clinical services include 24/7 support, condition education, medication management, symptom management, and appropriate proactive testing to avoid unnecessary emergency and inpatient utilization.

These integrated programs extend beyond pure clinical care to include the identification of and program support to relieve social determinants of health. Anticipated changes in the MA benefit allow for additional non-clinical services, however, these services will be most effective when integrated with the clinical program. Family caregivers, a key link in the member’s health care support system are typically included in these services.

Bringing Care to the Member’s Residence

An important factor for members with high-risk and chronic disease states is being able to bring care to them, anywhere they are most comfortable. It’s not uncommon for these members to have difficulty with transportation availability as well as the negative impacts travel can have on their health. In fact, a study found that 20% of new enrollees to AARP Medicare Supplement plans were homebound. Bringing care into the home improves access to care by making it easier to provide necessary and regular treatment.

When a multidisciplinary team is deployed to the home, the schedule and level of care are determined by the member’s specific condition and circumstances. Post-acute care may take place at the home of a family member for a time, shifting to the member’s home later with appropriate in-home support. Visit type and the clinician vary with the needs; a phlebotomist can support lab services in one visit and the patient educator can work with the member and family on managing symptoms in another visit. With this multi-team structure, visit frequency accommodates the member’s condition and needs and evolves as conditions progress.

Social determinants of health are often an elusive factor for office or clinic-based physicians, who rely on the patient to disclose their non-clinical needs. The data suggests that upwards of 40% of health care costs can be attributed to social determinants of health. By seeing patients in their home clinicians and social workers can identify and correct for social determinants with first-hand knowledge. Often these can be small things, like frayed carpet increasing fall risks, unsuitable food in the refrigerator for a restricted diet or obtaining medication co-pay assistance.

Health plans also understand that some members with complex needs reside in nursing or other types of facilities that may provide limited or insufficient care. By supplementing the facility care team with additional resources, the member can get timely care, avoiding emergency room and inpatient visits. Deploying supplemental care coordination resources help these members receive additional therapies that can improve quality of care and reduce costs.

Expanding the Use of Technology

Technology that supports telemedicine and remote clinical monitoring has exploded in recent years, creating even more opportunities for health plans to provide affordable and high-quality in-home care. New reimbursement and regulatory changes open the door for increased use of telemedicine. Improvements in technology and two-way cameras allow healthcare providers to remotely diagnose and treat patients, increasing access to care and reducing the time between provider visits.

Advances in Remote Patient Monitoring (RPM) devices that enable the monitoring of patient vitals and health stats outside of conventional clinic settings reduce costs and provide clinicians with timely, real-time information about their patients. Clinical applications include diabetes, dementia, and cardiac monitoring.

Health plans are consistently looking for new ways to reduce drug costs. The expansion of pharmacogenetics analytics and software put real-time personalized analytics into the hands of providers to detect physiological conditions that may alter the metabolism and efficacy of certain medications. These new tools prevent adverse drug reactions and decrease drug failure and non-optimized drug rates.

Adding telemedicine, RPM, and pharmacogenetics to the multidisciplinary care team extends its reach, promoting patient safety, enhancing patient care and giving clinicians timely clinical information to treat members in their place of residence – home or nursing facility.

Key Outcomes for Home Based Holistic Complex Care

Episodic programs and population health analytics have helped health plans reduce costs and improve clinical outcomes. As services and technology evolve, health plans that deploy an integrated, holistic multidisciplinary approach to treating members with complex needs can realize significant reductions in key metrics: emergency utilization, inpatient days, readmissions – all reducing medical costs and improving MLR. Perhaps more important, members and their caregivers realize the ultimate value of comprehensive in-home complex care—improved quality of life.