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Serving Complex Populations With Community-Based, Person-Centric Care
October 18, 2017

Serving Complex Populations With Community-Based, Person-Centric Care

Cardinal Innovations Healthcare is the largest specialty health plan in the country, insuring more than 850,000 North Carolinians with complex needs. Using a community-based model of care management, Cardinal Innovations has led the way in developing services, processes and solutions that improve the lives of our members and their families. Recognized for operational excellence, innovative solutions and superior outcomes for members, accuracy and speed of payments to providers, and cost-effective funds management, Cardinal Innovations is a leading healthcare company in the United States.
This article was written by Leesa Bain, RN, BSN, MHA is the vice president of care coordination and quality management at Cardinal Innovations Healthcare (headshot).
The numbers don’t lie about the need for community-based healthcare for our most complex and vulnerable member populations.
Consider this: Roughly 1 in 7 US adults (74 million people) are covered by Medicaid. Some of those individuals face complex intellectual and developmental disabilities (IDD). Others experience behavioral health issues and substance use disorders. While these beneficiaries only account for 23% of Medicaid enrollees, they comprise 61% of the total coverage costs. 
Most recent efforts to improve care quality by CMS have centered primarily on mainstream populations and their physical care. Yet the numbers make it clear: lowering coverage costs requires just as much focus on complex member populations who need other kinds of support in addition to physical health.
Some states already are taking new approaches to managing care for complex populations, like those with IDD, behavioral health, and substance use disorders. Cardinal Innovations Healthcare, for example, is spearheading a carefully constructed and comprehensive managed care strategy in North Carolina communities.
Cardinal Innovations believes that the key to enhancing care quality and lowering costs is to enable health plans, providers and community organizations to work together toward more coordinated, proactive and person-centric care. That includes addressing not only clinical factors, but also the social determinants of health that are so vital to successful outcomes for these populations.
Strategies for long-term success
A more integrated approach to managing complex member populations starts by moving beyond clinical care settings and extending services into the community. Community-based care drives more predictable costs, and goes a long way to making members’ lives better.
Here are 4 best practices for building a managed care strategy that accomplishes just that:
1. Tailor your efforts
It’s important to recognize that the demands of IDD, behavioral health, and substance abuse populations are inherently different than those with chronic physical conditions. These members require care plans tailored specifically to their unique needs.
For instance, these members typically have longer-term relationships with their care providers than other populations, and need highly individualized care plans that address both physical and social determinants of health. In order to enable these individuals to live in the community, treatment must entail close collaboration with medical, behavioral and other specialists.
Ensuring that the goals of each member are uniquely addressed in the care planning and authorization process is crucial. Interventions for IDD populations should be geared toward their preferred “quality of life” factors, which may include such activities as independent living, maintaining a job, volunteering, or getting married and having a family.
On the other hand, the needs of behavioral health and substance abuse populations are typically much more acute and crisis-oriented. Sometimes, they include a history of trauma that must be taken into account. Care may be shorter term, often in the 30- to 60-day range.
For these populations, best practices include assessing areas for improvement in each member’s most recent treatment plan. Plans should be rebuilt around those points to be certain that members receive the necessary care and support to succeed. For instance, some members may need assistance designed to maintain adherence to medications to maximize their ability to lead a high-quality life. For other members, “quality of life” is defined by their ability to live independently, free of crisis and stay out of the hospital.
Adding to this complexity is the fact that many of these individuals have multiple diagnoses. An individual with IDD may also have behavioral health concerns and a substance abuse disorder, for example. Oftentimes, additional physical comorbidities accompany these conditions, as well.
At Cardinal Innovations, clinical support teams provide an added level of aid for individuals with comorbidities. Through formalized technical assistance plans that reflect key elements of the CMS Final Rule of Home and Community Based Services, the clinical support teams identify those in need of help and assess the required intensity level. They incorporate person-centered planning, positive behavior supports, and trauma-informed interventions into their care plan.
This approach has garnered positive results, achieving a 55% decrease in unplanned crises and a 36% decrease in emergency department visits for enrollees.

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