A California foundation recently released a policy brief about 10 questions it hopes will serve as a guide for the rest of the country seeking to improve care for older populations with complex health needs in Medicaid managed long-term services and supports programs.
A California foundation recently released a policy brief about 10 questions (see infographic at bottom of the article) it hopes will serve as a guide for the rest of the country seeking to improve care for older populations with complex health needs in Medicaid managed long-term services and supports programs.
The 10 questions are now required by California Medicaid managed care plans, and The SCAN Foundation is hoping that health plans and healthcare systems consider using them for their own risk assessment instruments. The brief is called Ten Questions to Better Understand and Serve Your Complex Care Population.
In an interview with The American Journal of Managed Care®, Bruce Allen Chernof, MD, FACP, the foundation’s president and chief executive officer, said the report is central to The SCAN Foundation's work, which is to help organizations reimagine how they deliver healthcare to older adults. One of the foundation’s goals is to integrate Medicare and Medicaid and transform care for older adults.
Most of the time, he noted, senior citizens are viewed by doctors as patients in a chilly examining room wearing a paper gown, and doctors are focused purely on questions of a medical nature. “The medical questions are really important,” Chernof said. “I get it.”
What’s often overlooked, however, are questions that have to do with functional status and social determinants of health (SDOH). In other words, what’s going on for senior citizens when they are at home and not in a medical setting?
“When we think about social determinants of health we tend to think about younger adults and children,” he said, but they are “incredibly important questions for older adults.”
The 10 questions focus on daily living, the home environment, health literacy, social support, caregiver stress, potential for abuse, memory, fall risk, financial issues, and social isolation.
The SCAN Foundation said health systems are focused on using administrative and clinical data captured as part of medical billing to identify patients as high cost or high need. But older adults with chronic conditions and functional limitations cost twice as much to care for than those with chronic conditions alone.
In 2014, Cal MediConnect (CMC), a demonstration project, began looking at ways to align the financing and administration of Medi-Cal (the state’s Medicaid program) and Medicare services in 7 counties for dually eligible beneficiaries (low-income seniors) through capitated managed care plans. These 10 questions came out of that effort, and are now mandatory throughout the state as of January 1 for Medicaid managed care plans.
There are even more incentives to use questions like these to manage care for seniors, now that The CHRONIC Care Act and new CMS guidance promote functional and social needs as part of delivering more cost-effective, quality care.
Plans are required to collect the information and respond to the findings, and the state is using the information to evaluate for quality, said Chernof.
“The state basically says, 'you will ask these questions of everybody and you will act on them,’” especially if you have a contract and want to be paid, he said.
However, what is also important is that the answers are recorded and linked to care planning, because there is nothing more frustrating as a patient, and especially as a senior, to be asked the same questions over and over again by the medical community and then have nothing happen, he noted.
Additionally, this could be implemented more broadly, especially as health systems bear more and more financial risk, he said.
Another thing to keep in mind working with this population is that even if certain questions are asked - for instance, do you need help washing dishes or writing checks or doing yard work—it does not mean that the answers that come back will be accurate, whether because of denial or because the older adult is too proud to admit he needs help.
“This seems to be in a place of evolution—you can ask these questions and it doesn't mean that people will feel comfortable answering them,” Chernof said. “People aren't going to open up until they trust you. Sometimes asking once isn’t enough.”
In team-based setting, the nurse or social worker might be a better person to ask these questions, because they can spend more time with the patient, he added.
The key thing for all healthcare teams, he said, is to act on the information they receive. “You have to ask the questions at the right time in the right place with the right team.”
In his view, these questions should become part of the natural way of how older adults are treated in healthcare and it “shouldn't make any difference which door do you go through,” he said, whether it's Medicare, Medicare, fee for service, or a social service agency.
Chernof also said these questions could be considered just a starting point. For instance, he said he’d want to know more about social support—just because you have family members or others willing and able to help you when you need it says nothing about the degree or extent to which they would truly be willing to get involved in a 24/7 medical crisis. Depression screenings for caregivers, as well as older patients themselves, could be more robust, he said.
Chernof also mentioned a few different measures that can be used to understand success: fewer emergency department visits, fewer hospital readmissions that are ambulatory care—sensitive, and looking at the number of continuous days in the community in between hospital visits.
Besides California, the other state that is probably the closest to a similar uniform assessment tool is Minnesota, the foundation said.