Technical Assistance to Support Providers in Delivering Integrated, Coordinated Care to Beneficiaries Eligible for Both Medicare And Medicaid

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A downloadable version of this overview is available here.

The Medicare-Medicaid Coordination Office (MMCO) in the Centers for Medicare & Medicaid Services (CMS) is dedicated to ensuring beneficiaries enrolled in Medicare and Medicaid have access to seamless, high-quality health care that includes the full range of covered services in both programs.  To support providers in their efforts to deliver more integrated, coordinated care to Medicare-Medicaid enrollees, MMCO is developing technical assistance and actionable tools based on successful innovations and care models. MMCO contracted with The Lewin Group, along with the Institute for Healthcare Improvement (IHI), to assist with these efforts.  Summarized below are products from this contract and plans for additional work to help providers move along a continuum of more integrated, coordinated care.

Products And Technical Assistance

Provider guides and self-assessments. The Lewin team explored innovative provider practices through site visits, extensive interviews with experts, and an environmental scan.  With this information and input from a technical expert panel, Lewin identified four inter-dependent, high-level concepts that support the delivery of integrated, coordinated care: integrating physical health services into behavioral health organizationssupporting self-management for adults with serious mental illnessworkforce development to support care management, and navigation services for individuals with serious mental illness.  For each of these concepts, the team developed a provider guide to resources, promising practices, and tools.  Lewin also produced two organizational assessment tools for behavioral health providers on 1) integration and 2) self-management support.  The team is working with experts to refine assessment tools on workforce development and navigation, as well as other actionable tools to support the four concepts.

Disability-competent care self-assessment tool and webinars. The Lewin team partnered with the Disability Practice Institute (DPI) to develop a disability-competent care self-assessment tool for provider organizations to use in assessing their capacity to deliver disability-competent care.  The tool has been refined with input from additional experts, providers, and advocacy groups.  Lewin disseminated information about the disability-competent care model and tool through a series of webinars.  These webinars were attended by almost 800 individuals representing a wide audience of providers (e.g., nurses and social workers), health plans, and state Medicaid agencies. 

Managed care products. To better understand the role of home and community based service (HCBS) providers in improving the integration of care, the team conducted focus groups with providers and interviewed health plans.  Based on this information and input from the Association for Community Affiliated Plans (ACAP), the team developed multiple briefs on key considerations for health plans or providers as they begin to work together to better integrate care for Medicare-Medicaid enrollees. 

Care transitions toolkit and webinars. Lewin has been working closely with the Michigan Association of Community Mental Health Boards (MACMHB) to identify key information needs for providers who coordinate care for individuals with intellectual or developmental disabilities (I/DD).  To help address their needs, Lewin developed a care transitions toolkit tailored to providers for people with I/DD and targeted webinars about aging with I/DD.  The team also contracted with the Rehabilitation Research and Training Institute (RRTI), which provided training for health care professionals who work with this population on the mechanics, assessment, and management of pain. 

Planned Activities

Lewin will continue to build on the relationships it has established with DPI, ACAP, MACMHB, and RRTI in the coming year.  The team will develop targeted tools on aspects of disability-competent care and deliver real-time assistance as providers implement aspects of this care model.  The team will continue to collaborate with ACAP to identify opportunities to improve health plan capacity to meet the needs of Medicare-Medicaid enrollees.  ACAP members will help to vet and test tools developed under this contract, such as best practices to onboard and engage beneficiary representatives on governance boards and materials on overcoming barriers to implementing disability-competent care.  Training developed for MACMHB will be extended to providers across the state and the care transitions toolkit will be tested and refined for further dissemination.  RRTI will develop additional provider training modules on pharmacology and behavioral health issues for older people with I/DD.

The team seeks new relationships with states and provider groups to develop and disseminate additional technical assistance and new resources.  The Lewin Group will work with providers and plans to develop resources, for example, on promoting beneficiary engagement, coordinating with community resources, expanding the capacity of small HCBS providers, and targeting navigation support.  The current and planned resources will be disseminated through the dedicated website, Resources for Integrated Care (www.wordpress.test). Lewin will also investigate and engage in other activities to disseminate products to support the integration and coordination of care for Medicare-Medicaid enrollees.  

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