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


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.

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.

2. Establish a community-based care coordinator model

Establishing a community-based care coordinator model can empower organizations to directly support members, families, and stakeholders where they live, work, and play. The goal is to create high-quality, high-touch care coordination that fosters person-centered care plans.

As a guiding principle, the model should be set up to understand and make use of available community resources. These might include schools, the court system, the department of social services, local physicians, and more. A strong utilization management team with deep expertise in these member populations can authorize cost-effective services in the settings of the individual’s choice.

One example is the Transitions to Community Living (TCL) program, which helps people live in their own homes instead of in adult care homes or institutional settings. The Cardinal Innovations TCL team uses a person-centered, outcomes-focused approach not just to secure community housing, but also to establish the ongoing support services each individual needs for optimal care and healthy community living.

System of Care is another example of multi-agency collaboration in which child service agencies, including child welfare, mental health, schools, juvenile justice, and healthcare, come together to support youth and their families. A recent partnership between Cardinal Innovations System of Care team, North Carolina Families United, and the University of North Carolina Charlotte School of Social Work is helping to train social work students to meet these members’ needs.

With good community relationships, care coordinators can find the best resources for members and their families based on their wishes and in pursuit of the highest quality of life in the least restrictive situations.

3. Invest in your ecosystem

There’s no doubt that developing a managed care strategy for complex member populations requires investment—not just in technologies, but in staff, community resources, and training. The whole goal is to prepare communities to better identify and prevent health crises before they occur.

In North Carolina, Cardinal Innovations has extended both technical and non-technical assistance to community providers to help them better understand and address the needs of its members. Provider 360, for instance, is a program that offers resources, tools, and business training to help strengthen providers’ behavioral health practices. Likewise, Community Engagement services are designed to work with local community agencies—from court systems to jails to departments of social services—on educational and customer service opportunities.

Another example of productive stakeholder collaboration is an initiative called Partnering for Excellence (PFE). Through PFE, Cardinal Innovations and child welfare work together to provide holistic, early interventions for children who have experienced trauma. The services include trauma screening for children entering protective services, in-home and permanency services; an integrated care plan to ensure the child receives appropriate services from the start; and care management requiring Department of Social Services-involved families to work together to strengthen communication and coordination.

The investment in network providers and community agency relationships is critical. Through education and technical aid, they are better equipped to help members get the care they need before a crisis occurs—offering a more cost-effective approach to a higher quality of life.

4. Build community care collaboration

High-quality programs depend on the ability to nurture strong partnerships within the IDD, mental health, and substance abuse provider communities. They must also recognize that the physical care of these populations is, in many cases, managed separately by multiple physicians or hospitals.

Members may have chronic health conditions such as diabetes, high-blood pressure or asthma, for example. Medication management can be a challenge in these situations. Treatment for a member’s IDD, mental health, or substance abuse disorders may interfere with the treatment for those illnesses, or cause additional side effects.

Managing the complete needs of complex member populations is a constant juggling act. To achieve success, we, as an industry, must improve coordination across the entire care spectrum, and offer a more person-centric approach through co-located clinics and other member conveniences.

One of Cardinal Innovations’ health centers is a strong example of this in practice. As an integrated care facility, it provides a gateway that connects individuals with behavioral health and substance use conditions to a continuum of health services. These include on-site primary care, outpatient services, and mobile crisis with 24/7 access to crisis services.

One key to improved quality of life for these members is to offer recovery-oriented behavioral and physical health services in a long-term and sustainable manner.

Strong focus and increased collaboration for healthier outcomes

Regardless of how a state funds and manages Medicaid services, the bottom line is that it will take an increased commitment to collaboration to contain costs while enriching the quality of life for these members.

There’s plenty of opportunity to make a positive—and lasting—change for Medicaid beneficiaries. Wrapping them in holistic, community-based services helps create the true person-centered care that is the ultimate goal—and the way to better long-term outcomes.

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