Douglas McCarthy, Marian Bihrle Johnson
M. Bihrle Johnson and D. McCarthy, The Visiting Nurse Service of New York's Choice Health Plans: Continuous Care Management for Dually Eligible Medicare and Medicaid Beneficiaries, The Commonwealth Fund, January 2013.
The Visiting Nurse Service of New York created a managed care plan serving lower-income, vulnerable patients enrolled in a partially capitated Medicaid Managed Long-Term Care program or a fully capitated Medicare Advantage Special Needs Plan, or both. Every health plan member is assigned a care manager who collaborates with an interdisciplinary care team and the member’s primary care physician to enhance access to appropriate services, improve care coordination and transitions, and promote optimal health outcomes and independent living. Other key components of the model include comprehensive member assessments, patient and family education, transitional and palliative care provided by nurse practitioners, and the use of risk stratification, information technology, and staff training. Over time, Medicare plan members have experienced fewer hospital admissions, readmissions, and emergency visits. The health plan's experience should inform organizations and policymakers interested in integrating care for patients with special needs.