Case Management Initiatives for Enrollees of Medicare Advantage Programs

The Medicare Advantage market is growing, and with this, more individuals are selecting Medicare Advantage plans over traditional Medicare. Providers and payers need to tailor health plans to best meet the demands of an aging US population with complex health needs for their Medicare Advantage plan enrollees. Purpose: The purpose of this project was to create a comprehensive geriatric evidence-based assessment as part of care management practices within the health plan processes. Additionally, a topical outline of content was created, including a training module on traditional Medicare and Medicare Advantage and geriatric focused assessment tools grounded in a Medicare Advantage case study illustrating the case management process. This paper also demonstrated how a chronic care model with a charted workflow analysis can impact patient and systems-related outcomes of care by case managers in payer and provider roles within a Medicare Advantage setting. A comprehensive literature review was conducted for the best evidence-based care management assessment processes and models. Interviews were conducted with key stakeholders of the new Medicare Advantage plan to complete a workflow analysis and charting of the current case management processes within the proposed payer system. These processes and models were then synthesized for a comprehensive chronic care model with recommended geriatric assessment and interventions. They provided the foundation for a training module for case management tailored for Medicare Advantage enrollees. Best practices were gathered from a comprehensive literature review for best evidence-based practices, which included the US Preventative Services Task Force, as well as from an established chronic care model, called the Guided Care Model. The workflow analysis demonstrated how case management can be delivered within hospital and community settings using inpatient and outpatient workflow assessment charts for this payer group and using a geriatric-specific questionnaire to guide their comprehensive geriatric assessment. As a result, this project also provided a new learning module to train case managers on Medicare Advantage and how to implement a chronic care model with geriatric initiatives. Case management processes in payer settings can benefit from evidence-based and systematic applied methods of comprehensive care for their geriatric populations to improve patient-and system-related care outcomes. With more individuals choosing Medicare Advantage plans, healthcare providers and payers should guide their resources and training towards a geriatric chronic care model for this vulnerable population.