Patients with complex medical, social, and behavioral health needs require high-quality, personalized, round-the-clock care to improve health and self-management of chronic illnesses. Intensive services can reduce hospitalizations and nursing home placements.
Commonwealth Care Alliance, a nonprofit health system in Massachusetts that offers medical and social services to older people and the physically and mentally disabled, provides individualized primary care, behavioral health, and support services to its patients using multidisciplinary teams that are headed by nurse practitioners. The teams have broad leeway to order services—including transportation—without prior approval from the plan. The cost of providing additional support services is offset by reduced hospitalizations and nursing home placements.
The model sharply reduced hospitalizations among elderly patients. The number of hospital days per 1,000 members in 2007 was equal to 55 percent of hospital days for comparable patients who were cared for in a fee-for-service payment environment. For disabled patients, monthly medical costs were $3,061 in 2008 compared with $5,210 for Medicaid fee-for-service patients. The health system scored in the 90th percentile or above on Healthcare Effectiveness Data and Information Set (HEDIS) measures of diabetes care, monitoring of patients on long-term medication, and access to preventive care services.