HOW IT WORKS
The Massachusetts-based Commonwealth Care Alliance (CCA) One Care demonstration program serves individuals ages 21 to 64 who are dually eligible for both Medicare and Medicaid. Patient enrollment is either opt-in or passive, and there is a specialized intake team who follows a clear protocol for the assessment. Through this multidisciplinary assessment, CCA acquires data on an individual’s medical, social, and behavioral health needs, as well as social determinants of health (e.g., housing, education, food insecurity, loneliness, family support). Upon enrollment, patients are assigned a care partner, who becomes their first point of contact for all services and can reach out to other team members when specialty services are required, such as behavioral health, wheelchair/seating assessments, or long-term services and supports. For the sickest members, the care partner is typically nurse practitioner, behavioral health worker, licensed clinical social worker, or licensed mental health clinician, all of whom can meet the client in person, at home, or in the community. For clients who are more stable or have better community support, the care partner may manage them by phone. Each client is also assigned an individual team of health care practitioners, who work collaboratively to meet client needs, provide ongoing health management and early intervention, and respond to episodic and urgent care. A key feature of this team-based approach is the nurse practitioner’s authority and flexibility to request medical tests, medications, durable medical equipment (such as wheelchairs), dental care, eyeglasses, or transportation.
CCA had 11 locations and 16,000 contracted providers in 2018, with a total One Care enrollment of more than 18,000 members across Massachusetts. A preliminary analysis showed reductions in inpatient psychiatric facility stays, emergency department admissions, and costs per member, per month. A formal external evaluation of claims data is underway to compare health care spending, utilization, and quality compared to matched controls.
For providers. CCA’s interprofessional team includes community health workers, social workers, housing specialists, behavioral health specialists, pharmacists, and paramedics. Teams deliver care across settings. Care managers have responsibility for providing nonmedical services, using a standardized decision-support tool to determine patient needs and approve routine requests. One of the program’s hallmarks is the integration of physical health care with behavioral health and social services. The care model relies on the development of a preferred network and referral systems with various community entities.
For patients/caregivers. Services are tailored to patients’ needs, including nonmedical and end-of-life issues. Members and caregivers are encouraged to be active participants in their own care as members of the care team, and they collaborate with providers to establish goals. These goals may focus on clinical or quality-of-life concerns. CCA offers educational and online resources to support caregivers: guides and forms that cover medical history, medication records, and allergies; emergency contacts; a home-safety checklist; and more.
One Care is an initiative under the direction of the Medicare-Medicaid Coordination Office, the Center for Medicare and Medicaid Innovation, and Massachusetts. The Implementation Council is a working committee convened by the Executive Office of Health and Human Services (EOHHS), which runs the MassHealth (Medicaid) program. The council operates with 21 members, 11 of whom must be consumers. It plays a key role in monitoring access to health care, complying with the Americans with Disabilities Act, tracking quality of service, providing support and input to EOHHS, and promoting accountability and transparency. Massachusetts has successfully engaged stakeholders throughout the pilot process, in part because of the council’s efforts to solicit feedback.
The One Care program is a partnership among Medicare, MassHealth, and Massachusetts-based private insurers. The financial model relies on capitation rather than fee-for-service payment. Because the program tailors services to each patient's needs, it provides additional support that is rarely available or reimbursable in a fee-for-service model. The Centers for Medicare and Medicaid Services pays the Medicare portions of CCA rates, which are risk-adjusted by Medicare.
Laura Black, Vice President of Care Partnership and Clinical Services
Additional information on impact: Alternatives to Inpatient Psychiatric Services for Medicare-Medicaid Enrollees: A Case Study of Commonwealth Care Alliance, https://www.mathematica-mpr.com/our-publications-and-findings/publications/alternatives-to-inpatient-psychiatric-services-for-medicaremedicaid-enrollees-a-case-study