Care management (CM) is a team-based, person-centered approach “designed to assist patients and their support systems in managing medical conditions more effectively.”1 Care management includes a set of services and activities that help people with chronic or complex conditions manage their health, with an overarching goal of improving and maintaining health.
Care management includes those care coordination activities needed to help manage chronic illness. Unlike case management, which tends to be focused on managing disease, care management is organized around the idea that appropriate interventions for individuals will reduce health risks and decrease the cost of care.
Care management and coordination are key components of integrated, whole person care for individuals enrolled in both Medicare and Medicaid. Dually eligible beneficiaries often have multiple health care, behavioral health, long-term services and supports, and social service needs. Many face adverse social risk factors that may affect health status – social determinants of health (SDOH) – such as housing insecurity and homelessness, food insecurity, inadequate access to transportation, poverty, and low health literacy. This diversity and combination of needs underscore the importance of health plan care coordination for dually eligible beneficiaries that effectively assesses their range of needs; incorporates those needs and individual preferences and goals in person-centered care plans; and coordinates and shares information across all needed medical and non-medical providers and supports, including family and other caregivers.2
Resources for Integrated Care features practical resources for providers and plans providing care management and coordination to dually eligible beneficiaries. These products and webinars highlight promising practices, lessons learned, and stories from the field to support the delivery of integrated and coordinated care tailored to the needs of this population. Developed with input from a range of providers, plans, and other subject matter experts, these resources focus on the following topics:
Managing transitions is a key aspect of care coordination and helps ensure that beneficiaries undergo a seamless transition from one setting to another. These transitions may be from one health care setting to another, from a health care setting to home, or between health care professionals. Transitional care is based on a comprehensive plan of care and the availability of providers who are well-trained and have current information about the participant’s goals, preferences, and clinical status.
Community Health Workers
Health plans and providers seeking to provide culturally competent care and services to individuals from diverse backgrounds have incorporated community health workers (CHWs) in interdisciplinary care teams.3 CHWs are frontline public health workers who have an ethnic, linguistic, cultural, or experiential connection with the population they serve because they come from a similar background, speak the same language, or live in the same community as the individuals they support.4 They often serve as a bridge between members and the services they need.
3 Snyder, J. (2016). Community Health Workers: Roles and Opportunities in Health Care Delivery System Reform. Retrieved from https://aspe.hhs.gov/system/files/pdf/168956/CHWPolicy.pdf.
4 Resources for Integrated Care. (2017). Interdisciplinary Care Teams for Older Adults. Retrieved from https://www.resourcesforintegratedcare.com/ict/.
Community Supports & Resources
Collaborating with community partners that provide services beyond direct medical care such as housing, transportation for non-medical needs, and food can improve the ability to meet the various care needs of dually eligible members, improve overall health status, and ensure better outcomes for specific episodes of care.
Interdisciplinary Care Team (IDT)
An interdisciplinary team (IDT) brings together the knowledge and specialties from different health care disciplines to help participants receive the care they need. Through interdependent collaboration, open communication, and shared decision making, IDTs generate improved patient, organizational, and staff outcomes. Successful IDTs use a person-centered approach that prioritizes the individual’s needs.5
5 Resources for Integrated Care. (2017). Interdisciplinary Care Teams for Older Adults. Retrieved from https://www.resourcesforintegratedcare.com/ict/.
Navigation services can help providers deliver more integrated care to people with chronic or complex medical conditions. Such services include linking individuals (and their natural supports) with essential health and community services. Navigators coordinate care and services across siloed mental, behavioral, and physical health care delivery systems, leading to greater holistic and person-centered care.
Peer support staff are people in recovery from a mental health condition, substance use condition, or co-occurring condition who – with training – use their lived experience to assist others in their journey towards wellness and recovery. Evidence demonstrates that peer support can reduce inpatient and psychiatric hospitalizations, improve individual engagement in less costly outpatient care, strengthen relationships between people receiving services and their providers, decrease substance use, and increase social functioning and quality of life outcomes.6
6 Davidson, L., Bellamy, C., Chinman, M., Farkas, M., Ostrow, L., Cook, J., Jonikas, J., . . . Salzer, M. (2018) Revisiting the Rationale and Evidence for Peer Support. Psychiatric Times, 35(6). Retrieved from https://www.psychiatrictimes.com/special-reports/revisiting-rationale-and-evidence-peer-support.
1 Centers for healthcare strategies. Care management definition and framework (2007). http://www.chcs.org/resource/care-management-definition-and-framework/.
2 Barth, S., Silow-Carroll, S., Reagan, Russell, M., Simmons, T. (2019) Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches. Report to the Medicaid and CHIP Payment and Access Commission.