Care Coordination

This report highlights results from a 50-state GAO survey on what challenges states are experiencing related to federal Medicaid regulations. As part of the survey, GAO conducted interviews with state Medicaid officials to identify the areas of greatest concern. This report identifies four program areas that were rated as significant or moderate challenges to effective program administration. GAO also discusses potential federal actions to address these challenges

This case study examines the benefits of coordinating care for dually eligible members with serious mental illness. It looks specifically at how one Pennsylvania plan used a robust care coordination and member engagement model to successfully reduce urgent and unplanned inpatient admissions; and optimize health outcomes, quality of life, and self-management skills for individuals with serious mental illness.

This technical assistance tool focuses on the new “information sharing” requirement for Dual Eligible Special Needs Plans beginning in 2021. The tool explains the new requirement as well as how to address the requirement in mandatory D-SNP contracts.

CMS provided the president and Congress a report detailing the center’s action plan to provide support and technical assistance to states delivering supports to Medicaid beneficiaries with substance use disorder (SUD). The report outlines how CMS plans to implement requirements of Section 1018(a) of the SUPPORT for Patients and Communities Act in 2020-2021.

The Patient Centered Medical Home Network of The John A. Hartford Foundation Change AGEnts Initiative released a new paper titled, "Patient-Centered Medical Homes and the Care of Older Adults: How comprehensive care coordination, community connections, and person-directed care can make a difference.”

Justice in Aging published an issue brief that offers an analysis of the findings from the evaluation of the Financial Alignment Initiative (FAI), commonly known as the dual eligible demonstration. Research Triangle Institute was contracted by the Centers for Medicare and Medicaid Services (CMS) to conduct this evaluation, which focused on the first six months of operation of the demonstration in each of the seven states where it was rolled out.

The Centers for Medicare & Medicaid Services (CMS) began the Financial Alignment Demonstration in 2013 to improve care coordination. GAO was asked to examine care coordination under this demonstration. On January 19, The Government Accountability Office publicly released a report with their recommendations for CMS. GAO recommends that CMS develop new measures and align the current measures to improve oversight of care coordination.

The University of California San Francisco published a report about dementia care coordination for duals populations with a specific look at the inadequate workforce of dementia-capable care coordinators.Currently, there are twelve states in the process of implementing demonstrations projects. This report examined three-way contracts from seven states that were selected for their expertise in care coordination.

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an AAA in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Review the AHRQ study that gave the program a moderate evidence rating for improving outcomes, decreasing cost of care.