1. Commonwealth Care Alliance:
Care for Medicaid and Dual Beneficiaries with
Complex Care Needs Through Primary Care
Health Home Redesign
Robert J. Master, MD
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 1

2. Case Vignette
n Anna C. is a 55-year-old woman, SSI eligible Medicaid beneficiary with long
standing Multiple Sclerosis with complete paralysis in both legs, partial
paralysis in both arms and impaired bladder function. A long standing
history of depression, a prior major suicide attempt and a history of severe
asthma exacerbated by heavy smoking, predated her MS. For many years,
Anna was able to use a manual wheelchair and perform self
catheterizations but with slowly progressive upper extremity weakness this
became impossible. Anna has received two hours of PCA care each
morning and each evening for the past five years without adjustment
despite functional decline. During the past two years there have been
multiple hospitalizations for urinary tract infections, asthma exacerbations,
and two long sub acute hospital stays for pressure sore management
caused by extended hours in bed and a poorly fitted manual wheelchair. At
the time of enrollment, Anna was found to have no consistent primary care
or BH relationship and she was severely depressed, emotionally withdrawn,
functionally bedbound, incontinent, and with rapidly worsening decubitus
ulcers.
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 2

3. Why Does Anna C s Experience Cry Out
for a Health Home
§ Anna is an example of Medicaid and/or Dual Eligible
beneficiaries where care is totally inadequate and as a
consequence unnecessarily costly.
§ Predictable and preventable secondary complications, such
as, urinary tract infections, asthma exacerbations,
pneumonias and decubitus ulcers drive recurrent hospital
contacts, declining health, poor outcomes and most costs.
§ Primary care as resourced and organized in both FFS or MCO
iterations is hopelessly ineffective. Payer based care
coordination strategies are also hopelessly ineffective.
§ Needed LTC, DME and BH services are allocated (or not)
without any kind of an individualized care plan, monitoring or
sensitive modulation over time.
§ Continuity clinical management through all settings at all
times, is non-existent.
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 3

4. Commonwealth Care Alliance
n Non profit, fully prepaid care delivery, exclusively caring for Medicaid and
Dual eligible beneficiaries with complex care needs:
n 3000 Dual/Medicaid eligible elders – 70% NHC.
n 2700 younger Medicaid beneficiaries with multiple chronic medical and
BH conditions and/or disabilities.
Via
n 25 primary care practices in Massachusetts low income communities with
the following:
Primary Care Practice Redesign Elements
n Multidisciplinary clinical teams (RNP s, RN s BH clinicians, SW s, CHW s)
integrated into practices to enhance primary care and provide individuals
care coordination ($200-$600 PMPM costs).
n IT infrastructure from claims and clinical data to promote continuous care
improvement.
n 24/7 RN/RNP call availability with EMR support.
n Continuity management/coordination in all settings at all times.
n New in hospital nurse partners to promote safe and effective discharges
and seamless continuity
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 4

5. Health Home Redesign Element
n Comprehensive (often home based) multidisciplinary assessments, replace
typical physician H+P .
n Individualized care plans, resource allocations, monitoring and modulating by
the clinical teams for LTC, DME, BH services, replaces impersonal rule based
benefits.
n Clinical team empowerment to order and authorize all services, replaces
inefficient supplications to a distant Medicaid or BH carve out bureaucracies for
approval .
n Elastic RNP home response capability, to assess and manage new problems,
replaces the Ambulance and ED.
n For those with physical disabilities– integrated DME clinical assessment and
management, replaces distant PA processes and months of delay.
n For those in need of BH service, integrated BH clinician assessment,
individualized care plan development, implementation and management
replaces inaccessible vanilla BH carve out options .
n 24/7 clinical availability and continuity management replaces going it alone .
n Web based EMR support replaces total absence of clinical information transfer
capabilities.
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 5

6. Anna C.
Health Home Experience
n Comprehensive in home nurse practitioner BH clinician and PT and DME
assessment produced the development, implementation and monitoring of the
follow care plan:
n 72 hrs. of PCA support/week instituted for personal care, subsequently
reduced to 40 hours/week overtime.
n In home wound care nurse specialist consultation with a clinical
management plan instituted.
n Specialized air mattress delivered within 24 hours and motorized
wheelchair with needed seating adaptations quickly arranged for.
n In home BH assessment with individualized care plan created that
includes medication (SSRI s) and counseling.
n Transportation arranged for specialty appointments, dental care and
other activities.
n Smoking cessation strategies instituted.
n Primary care physician identified with continuous support by a nurse
practitioner provided as a first responder to, and clinical management of,
new problems via home visits.
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 6

7. Anna C. - One Year Later
n Engagement with life, family, community and in self management
greatly improved. Withdrawal and despondency diminished.
n Decubitus ulcers entirely healed.
n Effective BH psychopharmacology and LICSW in home counseling
relationship established.
n Smoking cessation efforts partially effective, frequency of asthma
exacerbations greatly diminished.
n Continuity relationship established with a PCP (through most
primary care occurs via RNP home visits) and with a Neurology
consultant.
n One year service use.
q 2 ED visits for asthma exacerbation management.
q One three day hospitalization for urinary tract infections management.
© 2011 Commonwealth Care Alliance, Inc. Confidential & Proprietary Information 7