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.

Running Head: Case Management Initiatives for Enrollees of MA Programs Case Management Initiatives for Enrollees of Medicare Advantage Programs Final Thesis Project Sherrie M. Harding Summer 2020 University of Utah Gerontology Interdisciplinary Program With special thanks to Committee Members: Brenda L. Luther, PhD, RN, Chair Linda S. Edelman PhD, MPhil, RN Gail L. Towsley, PhD, NHA, FSGA Case Management Initiatives for Enrollees in MA Programs 1 Abstract Background: The Medicare Advantage market is growing, and with this, more individuals are selecting Medicare Advantage plans over traditional Medicare. Providers and payors 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 payor and provider roles within a Medicare Advantage setting. Methods: 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 payor 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. Results: Best practices were gathered from a comprehensive literature review for best evidencebased 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 Case Management Initiatives for Enrollees in MA Programs 2 using inpatient and outpatient workflow assessment charts for this payor 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. Conclusion: Case management processes in payor 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 payors should guide their resources and training towards a geriatric chronic care model for this vulnerable population. Keywords: case management, case management training, comprehensive geriatric assessment, geriatric initiatives, Guided Care Model, Medicare Advantage, workflow analysis. Case Management Initiatives for Enrollees in MA Programs 3 CONTENTS Abstract ____________________________________________________________________ 1 Introduction _________________________________________________________________ 5 1. Literature Review __________________________________________________________ 6 1.1 Defining Medicare Advantage Versus Traditional Medicare Coverage ___________ 6 1.2 Population Characteristics for Medicare Advantage Enrollees _________________ 11 1.3 Comprehensive Geriatric Management Definitions __________________________ 13 1.4 Project Goals __________________________________________________________ 16 1.5 Target Audience _______________________________________________________ 16 1.6 Theoretical Basis for MA Program Implementation __________________________ 17 2. Methods _________________________________________________________________ 18 2.1 Literature Review for Best Practices of Care Management ____________________ 18 2.2 Workflow Analysis _____________________________________________________ 19 2.3 Proposed Interventions to Be Synthesized __________________________________ 21 3. Results __________________________________________________________________ 22 3.1 Evidence-based Geriatric Assessment of Best Practices _______________________ 22 3.2 Workflow Analysis _____________________________________________________ 24 3.2.1 MA Geriatric Assessment Program Needs ________________________________ 25 3.2.2 MA Plan Goals and Benefits ___________________________________________ 25 3.2.3 Case Management Workflow and Assessment Tools ________________________ 26 3.2.3.1 Identified Current Inpatient Workflow. _____________________________ 28 3.2.3.2 Identified Current Outpatient Workflow. ____________________________ 29 3.2.3.3 Identified Case Management Teams and Timeline of Case and Risk Assessments. __________________________________________________________ 30 3.2.3.4 Identified Assessment Tools. _______________________________________ 30 3.3 Comparison of GCM to Current Case Management Practice __________________ 34 3.4 Learning Module for Case Managers Demonstrating GCM and Assessment Process _________________________________________________________________________ 37 4. Discussion _______________________________________________________________ 42 4.1 Integration and Outcomes _______________________________________________ 42 4.2 Implications for Practice and Professional Development ______________________ 44 4.3 Implications for Health Policy ____________________________________________ 45 5. Conclusion _______________________________________________________________ 47 References _________________________________________________________________ 49 Appendix __________________________________________________________________ 61 Appendix 1: Guided Care Model _____________________________________________ 61 Appendix 2: Geriatric Depression Scale _______________________________________ 62 Appendix 3: CAGE Questionnaire ___________________________________________ 63 Appendix 4: Katz Index of Independence in Activities of Daily Living ______________ 64 Appendix 5: Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale ____ 65 Appendix 6: Learning Module Mockup _______________________________________ 67 Appendix 7: Geriatric Health Questionnaire ___________________________________ 86 Appendix 8: Workflow Assessment of Team Roles and Task Distribution ___________ 88 Table of Evidence ___________________________________________________________ 91 Case Management Initiatives for Enrollees in MA Programs 4 List of Figures FIGURE 1: GUIDED CARE MODEL FOR MA ENROLLEES _______________________ 16 FIGURE 2: WORKFLOW CHART FOR CASE MANAGEMENT ____________________ 28 List of Tables TABLE 1: GUIDED CARE (GCM) _____________________________________________ TABLE 2: STAKEHOLDER ROLES AND INTERVIEW QUESTIONS ________________ TABLE 3: SYNTHESIZED INTERVENTIONS ___________________________________ TABLE 4: US PREVENTATIVE SERVICES TASK FORCE (USPSTF) RECOMMENDATION FOR OLDER ADULTS ________________________________ TABLE 5: CURRENT ASSESSMENTS IN USE __________________________________ TABLE 6: EXAMPLE CASE STUDY WITH GERIATRIC ASSESSMENTS AND INTERVENTIONS _______________________________________________________ TABLE 7: RECOMMENDED ASSESSMENTS AND INTERVENTIONS FOR MR. JOHN FINCH _________________________________________________________________ 14 20 21 22 31 38 39 Case Management Initiatives for Enrollees in MA Programs 5 Introduction Traditional Medicare began with the passage of Title XVII of the Social Security Act during the1960s, which provides national health insurance coverage for millions of individuals within the US who are older adults, disabled, or have a specific type of chronic health condition (Wacker & Roberto, 2019). Traditional Medicare has four parts, called Part A, Part B, Part C, and Part D, which cover medical services and drug prescriptions (Wacker & Roberto, 2019). As an alternative to traditional Medicare, Medicare Part C, which was started in the 1980s, combines hospital and physician services into one healthcare plan and is now referred to as Medicare Advantage. The popularity of Medicare Advantage (MA) plans are growing, and the Congressional Budget Office projects that MA plans will cover almost 47% of Medicare beneficiaries by 2029 (Starc, 2014). With this increasing demand, insurance providers are offering more MA plans and access to services not covered by traditional Medicare, such as dental and fitness benefits (Freed, Damico, & Neuman, 2020). As the US population ages, more individuals are living with chronic conditions and disabilities. The occurrence of multiple chronic conditions also increases with age, especially for those who are 85 and over (Haber, 2016). As a result, older adults are at higher risk of experiencing complex healthcare needs and not receiving an appropriate level and type of care for their chronic health problems and disabilities (Bouchardy et al., 2007). The consequences for all of these issues can impact overall health and available resources for individuals. With the increasing demand for MA plans and the rising rates of comorbidities in older adults, providers need to tailor plans to best meet their enrollees' needs. A major insurance provider within the Intermountain West will be offering a new MA plan starting in Fall 2020. Incorporating this new MA plan with care management initiatives with a foundation of best Case Management Initiatives for Enrollees in MA Programs 6 evidence practices can help improve health status and decrease healthcare spending for enrollees. The purpose of this paper and project was to collect, synthesize, and ultimately provide best evidenced-based care management interventions and assessment tools for a comprehensive geriatric assessment within the health plan processes for older adults enrolled in Medicare Advantage. A learning module is also provided to train case managers on Medicare Advantage and how to utilize the recommended comprehensive geriatric assessment interventions with a case study. 1. Literature Review This literature review describes the following concepts: definitions of traditional Medicare and Medicare Advantage programs, population characteristics for Medicare Advantage enrollees, comprehensive geriatric care management definitions, and review of comprehensive geriatric care management recommendations. All of these concepts informed the design of a care management model of geriatric assessment designed for case managers, working in the new Medicare Advantage Program. 1.1 Defining Medicare Advantage Versus Traditional Medicare Coverage To understand how Medicare Advantage (MA) operates, a review of who qualifies, why it began, and how it is different from traditional Medicare is needed. Medicare was started as a national health insurance program benefit for older adults in 1965 under Title XVII of the Social Security Act (Wacker & Roberto, 2019). To be eligible for any Medicare benefit plan, an individual must also qualify for Social Security or Railroad Retirement benefits (Wacker & Roberto, 2019). Enrollees are typically aged 65 and over. Medicare is also offered to enrollees under age 65 if they experience end-stage kidney disease requiring dialysis or transplant or have been disabled for twenty-four months or longer or have Lou Gehrig's disease (Wacker & Case Management Initiatives for Enrollees in MA Programs 7 Roberto, 2019). The Center for Medicare and Medicaid Services (CMS) notes that around 63.2 million individuals are currently enrolled in Medicare, of which 59.2 million are 65 years and older, and 5.8 million are disabled (CMS, 2020). In traditional Medicare, enrollees have coverage across the country and may choose any provider that accepts it. Traditional Medicare also encompasses coverage for inpatient hospital services (Medicare Part A) and outpatient services (Medicare Part B) (Wacker & Roberto, 2019). Medicare Part A and Part B enrollees also have significant cost-sharing for these medical services (Starc, 2014). For example, Part A hospital coverage requires a consumer to cover a $1,216 deductible. Part B requires a consumer to cover 20% of overall physician services with no out-of-pocket maximum (Starc, 2014). To offset these costs, many consumers purchase supplemental plans, called Medigap policies, through their former employers or in the open insurance market (Wacker & Roberto, 2019). In general, health expenses are a more significant financial burden for older adults, especially those of lower socioeconomic status (Vasquez, Garcel, Ward, & Rodriguez, 2018). The Center for Medicare and Medicaid Services (CMS) found that many enrollees on Medicare are aged 65 and older and have an average out-of-pocket Medicare cost of $5,503 (CMS, 2016). Of note, the out-of-pocket medical costs increase with age. For example, people who are aged 65-74 had expenses at $4,676, people aged 75-84 at $5,745, and the cost rose to $10,208 for people 85 and over (Cubanski, Neuman, Daminco & Smith, 2018). These out-of-pocket costs comprise a significant part of an older adult's fixed income, given that half of the people enrolled in Medicare live off of $26,000 a year or less (Cubanski et al., 2018). As an alternative to save on out-of-pocket costs, Medicare Advantage (MA) was started in the 1980s under the name of Medicare Part C to provide consumers a choice other than Case Management Initiatives for Enrollees in MA Programs 8 traditional Medicare (Starc, 2014). MA offers consumer options to enroll in health maintenance organizations, preferred provider organizations, private fee-for-service plans, and other types of plans (Wacker & Roberto, 2019). Consumers must also live within a particular location where the MA is offered (Wacker & Roberto, 2019). Medicare funds MA plans by paying a set amount to the private insurance company, and consumers must use only hospitals and doctors within the medical provider/health system (Wacker & Roberto, 2019). Generally, a MA program is a closed network of hospitals and providers, which moves payment for services from a fee for service, like traditional Medicare, to paying providers on a per month, per member basis, and is referred to as a capitated payment system. With a capitated payment system, MA plan providers enter into a three-way contract with Medicare and a state to provide comprehensive, coordinated care at agreed upon costs (Mandal et al., 2017). The MA health plan/provider is paid for the risk of individuals enrolled in the program, which is called the risk adjustment factor (Mandal et al., 2017). All Medicare Part B recipients, including MA enrollees, pay a base premium for Medicare Part B benefits, which is $144.60 as of 2020, and premiums can be automatically deducted from their monthly Social Security check (Glazer & McGuire, 2017). In MA plans, the insurance providers decide how much it will pay providers and how much a consumer will pay for provided health services (Wacker & Roberto, 2019). Sometimes the premium may be more than $144.60, and the consumer may have to pay an additional premium for the MA plan (Wacker & Roberto, 2019). The popularity of MA has been increasing since its inception in the 1980s, and as of 2014, almost 30% of older adults who qualify for Medicare are choosing MA plans (Starc, 2014). Additionally, the Congressional Budget Office (2019) projects that MA plans will cover nearly 47% of Medicare beneficiaries by 2029. Although there are some reported survey Case Management Initiatives for Enrollees in MA Programs 9 differences in traditional Medicare versus MA, Cubanski et al. (2018) found that average out-ofpocket healthcare spending on premiums and services by MA enrollees was 26 percent less than out-of-pocket spending by beneficiaries in traditional Medicare in 2013. They found that MA enrollees have total out-of-pocket expenses at $4,316 versus traditional Medicare at $5,817. For an older adult with an average $26,000 fixed income, as noted by Cubanski et al. (2018), this can provide significant savings. Furthermore, Mandal et al. (2017) conducted a comparison study of a fee-for-service model versus a capitated model, which followed statistically similar community-dwelling older adults from 2009 to 2012. The study (2017) noted that for enrollees of a capitated MA plan, emergency department visits, and inpatient hospital admission decreased, which saved the capitated MA plan $2,071,293 per 1000 enrollees. Additionally, office-based care was increased for these capitated MA plan enrollees, which resulted in a 6% survival benefit and lowered the hazard of death by 32.8%. This study (2017) demonstrated that all stakeholders of the capitated MA program can benefit from this type of healthcare model. The CMS monitors the quality of MA plans through a star rating system. The star scale ranges from one to five stars, with a one-star rating for the lowest ratings to five stars for best performance. A MA overall plan’s star rating is determined by five domains, which includes staying healthy, chronic illness management, consumer experience with the plan, consumer complaints about the plan, and changes in MA plan performance (CMS, 2019). CMS annually reviews the five domains with feedback from clinicians and other stakeholders of the plan and verifies the reliability of plan measures (CMS, 2019). With a higher star rating quality, MA plan providers will receive monetary incentives for increased cost-effectiveness and for offering higher-quality plans with a 4-5-star rating (Wacker & Roberto, 2019). In addition to rewarding Case Management Initiatives for Enrollees in MA Programs 10 MA plan providers for higher quality and cost-effectiveness, the consumer is also rewarded by having a lower premium than the standard $144.60 Part B premiums charged (Glazer & McGuire, 2017). Around 78% of MA enrollees participate in plans that receive higher quality ratings, between 4 to 5 stars, with related bonus payments (Freed, Damico, & Neuman, 2020). With an increasing market share, available benefits are also expanding for MA enrollees. In 2019, CMS announced a change to MA plans to include supplemental benefits that are not covered in traditional Medicare Parts A or B (CMS, 2019). This CMS announcement (2019) noted that MA plans may offer in-home supportive or adult day health services under this expanded definition of supportive services. Other supplemental services may include nonmedical transportation and food delivery. Supplemental benefits are useful for MA enrollees with physical impairments, and can decrease the impact of a chronic health condition or injury and reduce emergency room visits (CMS, 2019). An example of a typical MA plan offered is the Regence Medicare Advantage PPO 2020. The Regence plan (2019) includes: • $0 premiums on select plans • $0 medical deductibles • Plans include basic vision and dental, or enrollees can add more expanded coverage for these services as a supplemental • Coverage beyond traditional Medicare, which provides for an annual physical exam, routine hearing exam and hearing aids • SilverFit Fitness Program, which provides an older adult access to free or discounted access to fitness centers • Telehealth with $0 co-pay Case Management Initiatives for Enrollees in MA Programs • Alternative care, such as chiropractic services • Home health and in-home safety assessment 11 Additionally, enrollees can access specialty care with a referral and not incur additional costs, such as traditional Medicare Part B, which requires enrollees to cover 20% of overall physician services with no out-of-pocket maximum or $1,216 deductible for Part A (Starc, 2014). For older adults on a fixed income, this MA plan may also provide savings and expand coverage for hearing aids, dental and in-home services. 1.2 Population Characteristics for Medicare Advantage Enrollees As the US population ages, more individuals are living with chronic conditions and disabilities. Likewise, the occurrence of having multiple chronic conditions increases with age, especially for those who are 85 years and over (Haber, 2016). Leading chronic conditions are hypertension, arthritis, heart disease, cancer, and diabetes (Haber, 2016). While addressing the medical issues associated with chronic health problems and disabilities, older adults are at higher risk for being either overdiagnosed and overtreated or underdiagnosed and undertreated, which can impact their overall health and resources available to them (Bouchardy et al., 2007). In addition to inadequate levels of care, Komaromy et al. (2018) observed that around 5% of the US population accounts for half of the overall healthcare spending and are identified as high-cost, high-care needs patients, experiencing frailty. Researchers also noted that within this population, frail older adults and younger patients who are disabled or end-stage renal disease account, the so-called “under-65” for the highest healthcare spending. Frailty is caused by multiple health contributors, which ultimately results in decreased function, strength, and resilience (Morley et al., 2013). Five symptoms of frailty include weight loss, exhaustion, decreased physical activity, reduced walking speed, and weak grip (Old & Woolley, 2014). Case Management Initiatives for Enrollees in MA Programs 12 Additionally, the under-65 disabled or with end-stage renal disease individuals may also increase healthcare spending due to poorly controlled chronic illness or a catastrophic event (Komaromy et al., 2018). Kenis et al. (2013) noted that untreated conditions could lead to further complications, such as increased functional impairment and fall risk. In this same study, Kenis et al. (2013) found that a comprehensive geriatric assessment will detect previously unknown conditions, such as functional impairments, within 40% of the patients. A geriatric assessment can also predict adverse outcomes for future treatment based upon current disabilities experienced within activities of daily living (Kenis et al., 2013). Activities of daily living encompass how well an individual can bathe or dress. Additionally, Ekdahl et al. (2016) found that comprehensive geriatric assessment-based care can reduce hospitalization and increase survival for older adults. Participants of this study (2016) were similar to the MA population in age and comorbidities, with being communitydwelling older adults who are 75 years and older and having three or more comorbidities. The study (2016) followed older adults within the intervention and control groups for 24 to 36 months. For the intervention group receiving a comprehensive geriatric assessment, these older adults had fewer mean days of hospitalization at 15.1 days when compared to the control group at 25 days. The intervention group also lived an average total of 69 days longer than the control group. This study (2016) found that the mean cost of care between the intervention and control group participants was the same at $65,000. A comprehensive geriatric assessment can help guide care and determine the greatest needs for MA enrollees and can be completed without increasing MA program costs. Case Management Initiatives for Enrollees in MA Programs 13 1.3 Comprehensive Geriatric Management Definitions Boyd et al. (2007) designed the Guided Care Model (GCM) (Appendix 1) to bridge the gap between the growing older adult population with multiple comorbidities and a fragmented health system. These researchers found that the current health system addresses acute healthcare needs but inefficiently manages chronic conditions for older adults. Because of the variability and nature of symptoms of chronic diseases, this population may also be inadequately informed and unprepared for the future care needs and the possibility of long-term care planning (Thorpe et al., 2015). Providers may also have an incomplete understanding of a patient’s perception of their chronic illness, which contributes to insufficient long-term planning (Kremenchutzky, 2013). To address these gaps in assessment and improve healthcare resource use, Boyd et al. (2007) enhanced the use of primary care by including seven Guided Care Concepts of chronic care within their GCM. The Guided Care Concepts include disease management, selfmanagement, case management, lifestyle modification, transitional care, caregiver support and education, and geriatric evaluation and management (Table 1). GCM is unique because it utilizes a registered nurse as a case manager, who is trained in the seven chronic care concepts listed. The GCM nurse works with two to five primary care providers and utilizes electronic health records to meet the needs of 50-60 older adults with multiple comorbidities. The GCM nurse also performs eight clinical activities, which would be applicable to the MA program. As noted by Boyd et al. (2007), the clinical activities would include the following (Table 1): 14 Case Management Initiatives for Enrollees in MA Programs _______________________________________________________________________________ Table 1 Guided Care (GCM) Guided Care Concept Clinical Activity Appendix of Assessment Assessment Initial assessment includes medical, functional, cognitive-affective, psychosocial, nutritional, and environmental evaluation. Other assessments to consider: • Depression Geriatric Depression Scale (Appendix 2) • Alcoholism CAGE alcoholism (Appendix 3) • Activities of Daily Living Katz Index of Activities of Living(Appendix 4) • Planning Chronic disease selfmanagement Monitoring Independent Activities of Daily Living The GCM nurse and Primary Care Provider will personalize a care plan for the MA enrollee, focusing on the enrollee's health literacy and accessibility under their personal electronic chart history, which will be referred to as "My Chart." The GCM nurse will also help MA enrollee with advanced care planning and determine their end of life wishes. With My Chart, MA enrollee can access their record anytime online with their unique login at the healthcare provider’s website. GCM nurse will encourage MA enrollee to utilize self-efficacy in managing their chronic illness. MA enrollee is offered free classes geared towards their specific chronic illness to better understand disease and management techniques. GCM nurse will monitor each MA enrollee by telephone monthly to address any urgent issues. Lawton-Brody IADL scale (Appendix 5) Case Management Initiatives for Enrollees in MA Programs 15 Coaching Motivational interviewing is utilized to increase enrollee’s participation and adherence to care plans. The GCM nurses are trained in motivational interviewing to assist in the process. Coordination of care GCM nurse will assist with primary care between providers and and coordination between different sites, other healthcare systems such as home health, transitions from hospital settings, and specialty care. Education and supporting GCM nurse will work with family caregivers members and other caregivers in providing education and support. Education may include group classes within the community or telephone consultations. Accessing community GCM nurse will assist MA enrollees in resources accessing appropriate community resources through the local Area Agency on Aging, such as Meals-on-Wheels or needed services, like home health. Boyd, C., Boult, C., Shadmi, E., Leff B., Brager, R., Dunbar, L., Wolff, J.L., Wegener, S. (2007). Guided Care for Multimorbid Older Adults. The Gerontologist, 47(5), 697–704. DOI: 10.1093/geront/47.5.697 In several studies, GCM has improved patient and caregiver’s perception of the quality of chronic illness, patient outcomes, and overall care of delivery (Boyd et al., 2007). With known results of using GCM, this model would show similar positive patient-and-system-related outcomes for MA plan enrollees. Boult et al. (2013) conducted a thirty-two-month study with MA, traditional Medicare, and Tricare plan enrollees utilizing GCM. Researchers found that higher-risk older adult participants of the study had an increased quality of life and decreased home health use. Although researchers did note that health function did not seem to improve, GCM was adopted by eight healthcare systems (Larsen, 2019). Case Management Initiatives for Enrollees in MA Programs 16 GCM for MA Enrollees Figure 1 Guided Care Model for MA Enrollees: Medicare Advantage (MA) enrollee is at the center of a Guided Care Model (GCM). GCM considers the enrollee's preferences and actions. Healthcare resources are utilized more efficiently for an enrollee within their given clinical state and setting. Coordination of care can assist in improving the quality of life, based upon best evidence-practice. 1.4 Project Goals This master's project goals were to provide a recommended comprehensive geriatric assessment model with interventions and assessment tools for enrollees of the new MA plan. With this assessment model and tools in place, enrollees will experience a comprehensive functional and cognitive assessment, including screening and prevention. Likewise, a learning module will provide case managers training on traditional Medicare and Medicare Advantage and how to utilize the recommended comprehensive assessment model and interventions with a case study. 1.5 Target Audience To utilize this new geriatric assessment model and interventions, all the stakeholders involved with new assessment tools used in case management and would be influenced by practice changes needed to be included within the targeted audience. The targeted audience was Case Management Initiatives for Enrollees in MA Programs 17 current case managers within the new MA plan and all the stakeholders who provide a collaboration of care for the MA population. Care processes was evidence-based and included consideration for all stakeholders to best meet the enrollees' needs to effectively incorporate the GCM and recommended assessment tools and interventions (Knickman & Kovner, 2015). Stakeholders included: • Hospital Administration • Providers (NP, PA, MD, nurses, and case managers) • Clinical Educators • Health Informatics • Finance • Support Staff • MA enrollee 1.6 Theoretical Basis for MA Program Implementation To promote the adoption of a new program by case managers and other providers, Lewin's (1951) Force-field analysis theory was utilized. Lewin (1951) stated that restraining forces cannot be removed, but they can be countered with an increase in a driving force. A restraining force, defined as resistance to change, may prevent overall change within an organization (Mitchell, 2013). For example, a nurse may not want to learn how to use a new infusion pump, which prevents a hospital from using new equipment or technology. A driving force, which is defined as a promotion for change, will need to be developed to overcome the resistance of a restraining force (Mitchell, 2013). Driving force examples may include incentives and recognition within an organization. For instance, explaining why the new pump is more effective and providing training on how to use it can incentivize change. Before the project was Case Management Initiatives for Enrollees in MA Programs 18 initiated, an assessment with leadership, clinicians, and staff occurred to determine possible restraining forces that may impede the program rollout. Likewise, the new program employed driving forces, like training, to improve project implementation. 2. Methods Evidence-based peer-reviewed literature was examined and synthesized to create best practices, including assessments and preventions/screening, to develop a comprehensive geriatric care management process specific for a MA program. A theoretical model was presented to provide a foundation of how this program will be implemented and utilized by case managers and health providers within the health plan system. A workflow analysis was also completed via conducting interviews with the key stakeholders of the new MA provider program to inform on the current processes. This project was deemed non-human subject research and is exempt by the University of Utah Institutional Review Board (IRB). As an evidenced-based quality innovation project, methods included interconnected building blocks of literature review, workflow analysis of current care management processes at the payor healthcare system, and recommendations for evidence-based assessment tools and best practices for a synthesized comprehensive care management program including screening and prevention tailored for MA clients. A training module was also provided to educate case managers on traditional Medicare and MA. A case study was included to demonstrate how to use the recommended geriatric model with current and new assessment tools. 2.1 Literature Review for Best Practices of Care Management A literature review encompassed collecting the best practice care management models and interventions for older adults, including ongoing strengths and functional assessments, and identifying a prevention plan with recommended screenings and preventive care. The literature Case Management Initiatives for Enrollees in MA Programs 19 review included the databases of PubMed, CINAHL Complete, and ClinicalKey. Settings for the searches on these databases included peer-reviewed articles published within the last five years and full-text availability. Key terms utilized for the literature review included the following terms used in single and combined word searches: capitated health care, care models, comprehensive geriatric care, geriatric care model, Guided Care Model, Medicare Advantage, older adult care model, traditional Medicare, value-based care, value-based outcomes, workflow, workflow analysis, and workflow charting. With this comprehensive literature review and best evidence-based practices gathered, case managers will be enabled to bridge existing gaps in a fragmented healthcare system to meet the needs of older adults with multiple chronic conditions. 2.2 Workflow Analysis Niazkhani et al. (2009) identified workflow elements that include the activities, tools, and processes needed to produce or modify work, products, or services. These researchers further identified clinical workflow as the activities, technologies, environments, people, and organizations engaged in providing and promoting health care. Assessment of workflow is essential because anytime a new process is introduced to change healthcare practice, the associated clinical and practice management workflow will also change (Health and Human Services, n.d.). One aspect of this project included a workflow analysis and was completed by interviewing the stakeholders of the new MA program. As noted by Niazkhani et al. (2009) and the Health and Human Services (n.d.), assessing clinical workflow with stakeholders is essential to understand current case management practice, introduce new processes, and modify clinical work. Interviews were conducted with the director of clinical operations, the nursing professional development practitioner (nursing educator), the Case Management Initiatives for Enrollees in MA Programs 20 MA plan administrator, and the supervisor case manager. Questions for these stakeholders encompassed the following (Table 2): Table 2 Stakeholder roles and interview questions Stakeholder roles Questions Director of clinical operations What type of assessments does the new MA plan need? Who should these new assessments and interventions be tailored for? What are the goals for the new assessments? Who are other individuals that I can interview for determining other needs of case management? Can I get current assessment tools being used for case management? **This individual also provided ongoing feedback throughout the project. Nursing professional What is the best format to deliver the new training development practitioner materials/module? (Nursing educator) Who can help me develop the new learning module based upon the materials from the project? What is the time frame for a learning module to be completed? MA plan administrator What are the overall goals and values for this new MA plan? How are you accomplishing this? What are the basic components of the plan? Are there expanded supplementals? What are the costs of the plan? Supervisor case manager What are the current assessments in use? Can I get copies of these assessments? Do you have a chronic care model in place? How are the assessments completed? What is the time frame for case management? How do you get referrals? Do you use risk assessment? How do you engage individuals with case management? Are their subgroups of case management? Do these case management departments work separately or together? Do you have weekly/monthly meetings to discuss clients? Do you participate in quality improvement projects? These stakeholders were selected based upon their key roles and participation within the new MA program. Questions asked (Table 2) during these stakeholder interviews provided materials and critical insight into the healthcare provider's clinical workflow. Additionally, 21 Case Management Initiatives for Enrollees in MA Programs results from these interviews provided information to visually map out and diagram current case management practices, processes, and workflow activities. 2.3 Proposed Interventions to Be Synthesized Proposed interventions are based upon peer-reviewed evidence-based practices found in literature and with demonstrated outcomes of care. The proposed care model used for the project is the Guided Care Model (GCM). In addition to the GCM model, other recommended geriatricspecific initiatives include preventative and screening recommendation outlined in the following (Table 3): Table 3 Synthesized interventions Concept Intervention Assessment Utilize the Geriatric Depression Scale, the CAGE alcoholism Scale, Katz Index of Independent Activities of Daily Living, and Lawton-Brody IADL Scale, and Mini-Cognitive Scale as assessment tools integrated within a comprehensive geriatric assessment. Create a mockup learning module Risk assessment Telehealth Home health Social determinants Reference (Sheikh & Yesavage, 1986) (Liskow, Campbell, Nickel & Power, 1995);(Katz, 1983); (Lawton & Brody, 1969); (Folstein, Folstein, & McHugh, 1975) Created a mockup learning module for case managers with integrated concepts for a comprehensive geriatric assessment. Segment patients for interventions (Sattar, Alibhai, Wildeirs, & based on clinical risk base Puts, 2014) Redesign patient flow with (Sattar, Alibhai, Wildeirs, & telehealth. Puts, 2014) Utilize team knowledge and team sharing during teleECHO sessions for providers. Extend in-home services, utilizing the Independence at Home demonstration program. Address the social determinants of MA enrollees, as many may also (Komaromy et al., 2018) (S.B.-870, 2017) (Sattar, Alibhai, Wildeirs, & Puts, 2014) 22 Case Management Initiatives for Enrollees in MA Programs Medication Spending have behavioral health and social complexities. Assess and focus on medication spending and utilization of generic medications. 3. Results (Sattar, Alibhai, Wildeirs, & Puts, 2014) 3.1 Evidence-based Geriatric Assessment of Best Practices The US Preventative Services Task Force (USPSTF) is an independent panel of experts in primary care and prevention that screens and reviews clinical evidence for effectiveness. It then develops recommendations for clinical preventive services (Huckstadt, 2019). The clinical conditions covered include a range of health issues from chronic illnesses to mental health. Recommendations are then provided on screening, counseling, and preventive medication topics for these health issues. For the enrollees of the MA programs, USPSTF recommends the following for screenings and prevention assessments for older adults (Table 4): Table 4 US Preventative Services Task Force (USPSTF) recommendation for older adults Screening Description/Clinical Reasoning Year of Published Recommendation Hepatitis C Virus Hepatitis C is the most common blood2020 Screening borne disease pathogen within the US and is a leading complication for chronic liver disease. Hepatitis B Virus Clinicians should screen for hepatitis B 2014 screening infection in persons who are at higher risk for infection. Unhealthy drug use Recommended screening by asking about 2020 Screening unhealthy drug use for diagnosis, effective treatment, and access to appropriate services. Abdominal Aortic A one-time screening is recommended for 2019 Aneurysm Screening abdominal aortic aneurysm for men 65-75 who have never smoked. Breast cancer Prevention Clinicians should prescribe risk-reducing 2019 medication to women who are at increased risk for breast cancer and low risk for adverse medication effects. 23 Case Management Initiatives for Enrollees in MA Programs BRCA-Related cancer Screening Lung cancer screening Unhealthy alcohol Screening Intimate partner violence, elder abuse, and abuse of vulnerable adults screening Exercise interventions to prevent falls Weight loss to prevent obesity-related morbidity and mortality Cervical Cancer screening Osteoporosis screening Abnormal blood glucose and Type 2 Diabetes Mellitus screening Hypertension screening Tobacco/smoking screening Sexually transmitted infections screening Clinicians should assess women with a personal or family history with breast cancer susceptibility to 1 and 2 BRCA genes are screened with a risk assessment tool. Screening should be completed for adults aged 55-80 who have a 30 pack-year smoking history and currently smoke or have quit within the last 15 years. Screening for unhealthy alcohol use should be completed by clinicians in a primary care setting and provide brief behavioral counseling interventions to decrease unhealthy alcohol use. Clinicians should screen for abuse within these populations, provide counseling and referrals. 2019 Clinicians should recommend exercise for adults aged 65 and older and who are at increased risk for falls (history of falls). Clinicians should offer or refer adults with a body mass index of 30 or higher to behavioral interventions to promote weight loss. Women between the ages of 21-65 should be screened every three years with cervical cytology and every five years with highrisk human papillomavirus. Screening for osteoporosis with bone measurement testing in post-menopausal women and women 65 and older to prevent osteoporotic fractures. Adults aged from 40-70 who are overweight or obese should be screened for abnormal blood glucose as a part of cardiovascular risk assessment. Clinicians should screen for high blood pressure in adults aged 18 and older. Clinicians should ask all adults about tobacco use, advise to stop, and assist in providing behavioral interventions for cessation. Clinicians should screen for sexually transmitted infections in all sexually active 2018 2014 2019 2018 2018 2018 2018 2015 2015 2015 2014 24 Case Management Initiatives for Enrollees in MA Programs Preventative use of statin medication Depression screening adults and provide behavioral counseling to reduce transmission infection risk. Adults age 40-75 with a history of one or more cardiovascular disease (CVD) risk factors, such as smoking or having diabetes, and a calculated ten-year CVD risk event of 10% use low to a moderatedose statin to prevent a CVD event. The general adult population should be screened for depression and should include systems in place to provide an accurate diagnosis of effective treatment and follow-up. 2016 2016 US Preventative Services Taskforce. Recommendations https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics These USPSTF recommended screenings are endorsed by the American Academy of Family physicians and are recognized by the Institute of Medicine as a model for developing evidence-based practice guidelines (Siu et al., 2016). These recommended screening should be used in conjunction with the GCM for older adults enrolled within a MA program. 3.2 Workflow Analysis Interviews were conducted with four team members who are key stakeholders overseeing the new MA program. These team members provided material information about the new MA program and assessments used by case managers for the general population as well as a review of current care management processes within the health system. Interviews were conducted with the director of clinical operations, the nursing professional development practitioner (nursing educator), the MA plan administrator, and the supervisor case manager. Questions asked during these interviews are outlined in Table 2, and answers are discussed within the workflow section. These interviews provided an understanding of the MA program's needs for geriatric interventions and assessment tools. MA plan administration also offered insight into the MA plan goals and how the new MA plan can benefit enrollment. The supervisor case manager also Case Management Initiatives for Enrollees in MA Programs 25 explained how case managers get referrals, conduct assessment, and what are the specific workflow paths for their clients. 3.2.1 MA Geriatric Assessment Program Needs An interview was conducted with the director of clinical operations to ascertain what type of assessment tools were needed for the MA program. The director identified that the MA program did not have a specific geriatric tool for assessing older adults and that current assessment tools are geared toward a younger population. The director also stated that the program needed an assessment tool that is more specifically tailored for older adults who will be enrolling in the MA program. The director noted that creating a learning module to train case managers on how to use and conduct a geriatric assessment would be needed. Meetings were also conducted with the director throughout the rest of the project to get ongoing feedback with literature review results and opinion of new assessment tools identified. To follow up with the learning module request from the director, an interview was conducted with the nursing professional development practitioner (nurse educator) to examine how a learning module may be created. The conversation explored ways on how to present a new assessment and demonstrate how to utilize it. One possibility was to create a learning module that could be used in conjunction with the current hospital online educational learning department. The learning module is expected to take approximately 4-6 weeks to be created once the material was presented to this department. 3.2.2 MA Plan Goals and Benefits By including administration, a larger-scale examination provided insight into how the MA plan will fit the needs of new MA enrollees. While conducting a phone interview, the MA plan administrator discussed the importance of the MA goals to older adults. The plan Case Management Initiatives for Enrollees in MA Programs 26 administrator stated that the MA program goals were to provide good value for enrollee’s healthcare dollars while also meeting their healthcare needs. The plan administrator noted how the MA program expanded coverage beyond traditional Medicare to include coverage for dental and hearing and providing supplementals for home health needs. The plan administrator also stated that generic medications were going to be used to keep the prescription cost down, and the MA plan will include zero-dollar premiums and deductibles. 3.2.3 Case Management Workflow and Assessment Tools After examining the geriatric assessment needs and overall population characteristics for the MA program, an evaluation of the current workflow of case management processes was conducted with the supervisor case manager identified for the new MA plan. The meeting included a discussion on workflow practice and what a geriatric-specific assessment tool can do for case managers working with the new MA plan enrollees. The supervisor case manager also completed a Workflow and Task Distribution form (Appendix 8) that demonstrated how work is shared among case managers, providers, and office support personnel. While completing this form, the supervisor case manager also noted that the work performed by “RN” and “Case Manager” listed on the form is completed by one person, the nurse case manager. The supervisor case manager discussed how referrals for case management come from various sources for individuals currently hospitalized (inpatient) and those out within the community (outpatient). It was also found that there is not a specific care model being used, but elements of chronic care are currently in place with case management. The supervisor case manager described how referrals sources come from inpatient hospital providers, the utilization review and the risk assessment departments within the hospital, and outpatient health care providers. Once case management gets a referral from either an inpatient or outpatient source, a Case Management Initiatives for Enrollees in MA Programs 27 referral will take a workflow path for inpatient or outpatient. This workflow assessment is based upon recommendations on workflow analysis from the Department of Health and Human Services (n.d.). The Department of Health and Human Services (n.d.) noted that a workflow chart provides visualization of a workflow by showing the sequence and interactions of steps, decisions, and activities involved. The workflow also clarifies key working processes and identifying who performs what activities and tasks. With this defined idea of workflow, Figure 2 visually represents the workflow process for case management that I uncovered through interviews and analyzing the case management assessments currently in use at the major insurance provider. Case Management Initiatives for Enrollees in MA Programs 28 Figure 2 Workflow chart for case management: This chart visually diagrams the workflow process used in case management (CM) practice. After a referral is provided to case management, the referral goes through a process step of inpatient or outpatient workflow path. Decision findings from the assessment determine the process steps of case management activities. Activities range from medication reconciliation to accessing community resources. Inpatient and outpatient workflows have defined time frames and may end when defined care goals have been met, or change occurs with insurance coverage or providers. Communication, collaboration, and coordination of care can also occur between both workflow paths for their clients. 3.2.3.1 Identified Current Inpatient Workflow. An assessment occurs between the case manager and the client over the phone and will take around sixty to ninety minutes to complete. A case manager completes a needs assessment, including determining a client's level of understanding of their acute or chronic illness to identify educational needs on their disease trajectory. Case managers also assess the current health status and activities of daily living and instrumental activities of daily living. Clients are also assessed for social determinants of health Case Management Initiatives for Enrollees in MA Programs 29 to ascertain if they are experiencing any social or behavioral complexities that may affect their care. Once the assessment is complete, a case manager works with the client to create a care plan with mutually determined care goals. The supervisor case manager also noted that case management activities are dependent upon the care plan and goals. Activities include accessing community resources, providing home health, monitoring a client's health status, providing care collaboration with other providers, and providing referrals dependent upon the patient’s health status. Communication, collaboration, and coordination of care can also occur between inpatient and outpatient workflow paths for their clients. The supervisor case manager indicated that inpatient case management's typical time frame would run up to 30 days post-discharge from the hospital. 3.2.3.2 Identified Current Outpatient Workflow. For the outpatient workflow, the supervisor case manager noted that when a referral is made to case management, the department makes up to three attempts to reach its clients to engage with case management. Methods of communication include phone calls, emails, and regular mail within a two-week period. Once a client agrees to participate with case management, an initial phone assessment will occur and take about ninety minutes to complete. The initial assessment includes reviewing the same areas as inpatient clients, like the educational needs of disease, chronic illness management, assessing health status, and addressing social determinants of health. The case manager can also assist with advanced care planning. The supervisor case manager also stated that the time frame for case management generally lasts six months to a year. Outpatient management activities are the same as an inpatient, and include case management referrals, accessing community resources, providing home health, home inspection, care collaboration, and teaching. The supervisor case Case Management Initiatives for Enrollees in MA Programs 30 manager also noted that the teach-back method occurs with clients at the end of the visit and that case managers provide health coaching and motivational interviewing. Communication, collaboration, and coordination of care can also occur between inpatient and outpatient workflow paths for their clients. 3.2.3.3 Identified Case Management Teams and Timeline of Case and Risk Assessments. For inpatient and outpatient clients, the supervisor case manager stated that case management cases might be closed for several situations, including aftercare goals have been met, insurance has changed, or clients are no longer members of the particular healthcare group or provider plan. It was also mentioned that there two care management teams that oversee care, which include regular case management and utilization case management review. Both teams have around twenty case managers. The supervisor case manager noted that care team conferences use to occur monthly to discuss cases and the current status of clients up until a few months ago. These meetings ended as a result of the current health pandemic. Case managers also participate in quality improvement and practice improvement activities. During the workflow analysis interview, it was also noted that a risk assessment department is utilized to determine patients' health risk scores that may need care management intervention. The risk assessment system is also upgrading to a data risk analysis system that assigns a health risk scores based upon diagnoses, hospitalization, age, adherence to medications, and medical treatments. The higher the risk score, the greater the need for case management intervention. 3.2.3.4 Identified Assessment Tools. Case managers access assessment tools through a computerized charting system, where questions may be yes or no selections, which will help guide the clinical flow to other needed sources. Other components of assessments have a free 31 Case Management Initiatives for Enrollees in MA Programs texting area for notes. The type of assessment depends on whether the client is inpatient or outpatient, source of the referral, chronic illness, and if there are any behavioral or social complexities needs identified. Assessments currently in use by case managers at this healthcare provider that would be applicable for a comprehensive geriatric assessment for older adults and their caregivers include the following (Table 5): Table 5 Current assessments in use Assessment Name Assessment Use AD8 Assessment of cognitive status and level of functionality Activities of daily living and instrumental activities of daily living ADL-IADL Assessment Assessment of activities of daily living and instrumental activities of daily living American Society of Addiction Medicine (ASAM) Addiction, drug, and alcohol use Assessment Function Determines if cognitive and/or memory impairment is occurring, and also addresses caregiver needs. The assessment helps establish collaborative care, follow up with community resources, and provides a clinical pathway for referrals. Determines functionality and ability to complete everyday activities of daily living, like bathing or dressing and instrumental activities of daily living, like shopping for food. Also determines care needs based upon how well ADLs and IADLs can be completed by individual independently. The assessment identifies any needs for referral, a collaboration of care, accessing community resources, disease management, addressing caregiver needs, and provides teaching and education regarding illness/disease trajectory. Determines the risk level of drug and alcohol use. The risk score is assigned based upon questions. The risk range is Case Management Initiatives for Enrollees in MA Programs Adult behavioral health Assessment of mental/behavioral status and/or substance/alcohol use Caregiver Activation Measure (CAM) Assessment of caregiver 32 from 0-4, with 0 being low risk to 4 needing immediate intervention. Different levels and interventions are dependent upon the score from the assessment. Interventions range from seeing a counselor for behavioral modification assistance to immediate hospitalization. The assessment determines the individual's needs for mental or behavioral health, and if an immediate acute/crisis situation requires immediate intervention. The client is also assessed for substance, nicotine, or alcohol usage and if interventions are required. Interventions may include teaching or education, referral to a doctor/counselor for treatment, a collaboration of care, or immediate intervention with behavioral health. Assessment of caregiver for strain and depression. The assessment also includes questions on how well the caregiver understands illness/disease management for individuals receiving care, prescribed medications, and community resources utilization. Case management activities may include referral to community resources, teaching/education of chronic illness, social work to assist with financial counseling and Medicaid application, and counselor referral for mental health. Case Management Initiatives for Enrollees in MA Programs Chronic disease assessments including Asthma, Atrial Fibrillation, Cancer, Chronic Kidney Disease-End Stage Renal Disease, Chronic Obstructive Pulmonary Disease (COPD), Cerebral Vascular Accident (CVA)Stroke, Diabetes, Heart Failure, HIV, Sickle Cell, and Rheumatoid Arthritis Assessment of disease history and management of chronic disease Emergency Department Follow-up Assessment of need for an emergency department visit Medicaid Assessment of Medicaid qualification Post-discharge from hospital Assessment of health after a hospital stay and follow up needs 33 After assessing disease history and management of disease, interventions include follow up with a provider, education on disease trajectory, medication reconciliation and management, caregiver assistance, a collaboration of care, and access to community resources. Case manager also helps to establish a care plan with mutually defined goals with a client. Client is assessed for the health issue surrounding the emergency visit if it was resolved or if additional care management actions are needed. Assessment may include whether follow up is necessary for chronic disease management, behavioral health, substance abuse, and addressing prescription and social determinants of health (SDOH). Assessment helps to determine if the individual may qualify for Medicaid. Case management provides a referral to social work to assist the client with the Medicaid application process. Follow up with the patient after discharge from the hospital to determine health status and post-discharge health needs. Discharge needs may include home health, care collaboration, setting appointments with providers for clients, accessing community services, and 34 Case Management Initiatives for Enrollees in MA Programs Readiness for change Assessment for behavioral modification for disease management Social determinants of health (SDOH) Assessment of social and environmental complexities Tobacco-nicotine use Assessment of tobacconicotine use teaching/education of chronic disease or illness. Assessment determines how ready an individual is to change or modify behavior to improve health or increase adherence to medical/prescription needs. Assessments address mental, physical, and environmental complexities that the client may be experiencing. Case management activities may include accessing community resources, a collaboration of care, teaching/education of disease management, referral to primary care providers and/or behavioral health, and assistance with Medicaid application. Screening and interventions to prevent to reduce tobacco or nicotine use. 3.3 Comparison of GCM to Current Case Management Practice The Guided Care Model (GCM) was recommended as a chronic care model for this new MA program within this project. While investigating the current practice, the supervisor case manager revealed that case management does not have a formal care model but uses elements of chronic care. However, based upon analyzing current assessments in use and results from the interview conducted with the supervisor case manager, it was found that case management utilizes all the recommended aspects of the GCM. The result findings from the interview included that case managers use assessment planning, chronic disease self-management, provide collaboration of care, coaching, monitoring, and accessing community resources for their clients. Case managers have a caseload of around 60-120 clients and utilize electronic health records to Case Management Initiatives for Enrollees in MA Programs 35 complete assessments and case management activities. As noted by the supervisor case manager, once a referral is provided to case management, a phone assessment is conducted with new clients and can take around sixty to ninety minutes to complete. Like the GCM, the initial assessment includes medical, functional, cognitive-affective, psychosocial, nutritional, and environmental evaluation. Additionally, case management follows clients through inpatient and outpatient pathways with defined timelines and activities, and creates a client-centered care plan with mutually determined care goals. Although current assessment tools in place are different than the recommended ones, they include the recommended components of a comprehensive geriatric assessment. By comparing the recommended assessment versus what is currently utilized, a synthesized program with geriatric initiatives can be implemented. For cognitive assessment, the mini-cognitive test was recommended, and in use, the AD8 is utilized currently if cognitive impairment is suspected. The AD8 is a more comprehensive assessment than the mini-cognitive test. The suggested synthesis is to use a mini-cognitive test for a quick cognitive assessment, and then if cognitive impairment is found, the AD8 could then be followed up with. For assessment of activities of daily living and instrumental activities of daily living, the Katz Index (Appendix 4) and Lawton-Brody IADL (Appendix 5) scales were recommended. The ADL-IADL assessment currently in use incorporates all the recommended assessment elements and therefore are adequate for assessment needs. For alcohol use, the CAGE questionnaire (Appendix 3) was recommended. In use, the American Society of Addiction Medicine (ASAM) provides a more in-depth assessment to explore addiction, alcohol, and drug abuse. The CAGE questionnaire may, therefore, be Case Management Initiatives for Enrollees in MA Programs 36 appropriate for a quick evaluation of alcohol use. When appropriate, follow up with the more indepth ASAM if a positive indication of addiction or drug abuse is shown. In addition to ASAM, the Adult and Behavioral Health assessment also explores addiction and overall behavioral health. Assessment of depression is explored within this, and therefore the Geriatric Depression Scale (Appendix 5) would not need to be utilized as an additional assessment tool. Other utilized assessments include specific chronic illnesses (Table 5) that can assist with teaching enrollees about their disease process, management, and future needs. In conjunction with chronic illnesses, case managers are also assessing the social determinants of health, which was noted as an item to be synthesized within the geriatric interventions. By tailoring assessments in the new GCM guidelines to the client’s chronic illness and incorporating the social determinants of health, a case manager can access needed community resources to manage environmental issues that may exacerbate a client’s current health status. Care goals are mutually defined with the client to best meet their needs and to help them achieve their care goals. During this project's development, a geriatric assessment tool that provides a quick assessment of multiple health systems was found and shared with the director of clinical operation as a possible option for a synthesized geriatric intervention tool (Appendix 7). The director of clinical operations subsequently incorporated this into current assessment tools early on during the project because it met the criteria need for geriatric-specific tools for the MA plan. The assessment was created by the Iowa Geriatric Education Center (2020) and is called the Geriatric Health Questionnaire. It is recommended as an intake form and provides a quick review of all general health and pain. It first assesses how well individuals can complete their activities of daily living and instrumental activities of daily living. It then provides a general review of health systems, ranging from the bladder function to hearing and eyesight. The form also Case Management Initiatives for Enrollees in MA Programs 37 contains questions on alcohol use, advanced care directives, caregiver needs, and preventive care. The final section of the form test memory and cognitive status with a mini-cognitive test of three words and a clock test. As an assessment tool, it provides a quick summary of health systems and allows for a case manager to follow up in areas that are noted to be irregular or needing further investigation. It also easily incorporates advanced care planning. Other components that were suggested to be synthesized include risk assessment, medication spending review, and telehealth, as recommended by Sattar et al. (2014). All of these suggested items were already used in everyday practice within the case management department. The director of clinical operations and supervisor case manager both discussed how risk assessment for patients is in use and is currently getting an upgrade. Additionally, risk assessment is one of the departments that provides initial referrals to case management for follow-up. For medication spending, the MA plan administrator stated that one of the goals was to provide good value for their enrollee's health dollars. To accomplish this goal, the MA plan will be using generic medications to keep the prescription cost down. This MA health plan is also using telehealth by case management and other providers. Case management completes assessments with clients by phone and provides coaching, teaching, and motivational interviewing for their clients as part of ongoing care. The MA plan will provide telehealth at $0 cost for enrollees. 3.4 Learning Module for Case Managers Demonstrating GCM and Assessment Process A learning module (Appendix 6) was created as part of this project and provides a demonstration on how to organize and teach case managers about MA. It illustrates how the GCM with geriatric initiatives could be implemented within a case management practice to provide professional development. A case study (Table 6) is an example of how to help case Case Management Initiatives for Enrollees in MA Programs 38 managers experience screening and completing recommended assessments (Table 7) for their professional development in any healthcare payor setting. ____________________________________________________________________________ Table 6 Example case study with geriatric assessments and interventions Client information: Referral type: Risk assessment Client name: Mr. John Finch Gender: Male DOB & Age: July 12, 1948-Age 72 Current Residence: Personal home-233 East Main St. American Fork, UT 84003 Marital status: Married Race: Caucasian Language: English Education: Bachelor’s in Education Code Status: DNR/Advanced Directives Client history: Mr. Finch was admitted to the hospital one week ago for having a “cold left leg” and non-healing left foot ulcer. He subsequently had emergency surgery to amputate his lower left leg, due to having no circulation (ischemia). When asked about his health and pain level, Mr. Finch states that his health is “generally poor” “and is “in constant pain" at his left leg stump surgical site. The client has an 8-year history of type 2 diabetes, underwent a coronary artery bypass five years ago, has end-stage kidney disease, and has a right arm arteriovenous fistula. The client also experiences anxiety. The client receives hemodialysis three times a week, and his wife drives him to all of his dialysis appointments. Mr. Finch lives at home with his wife, Julia Finch, in American Fork, where they have lived for the last 32 years. The client is oriented to familiar surroundings but recently started to experience cognitive decline. Before his lower left leg amputation, he was able to ambulate with a walker. He is generally independent with his activities of daily living. He can dress his upper and lower body but needs stand-by assistance while bathing. He can no longer manage his finances. Mrs. Finch is anxious about being able to drive her husband to and from dialysis now with his amputated limb. She would also like to know what community services are available for caregiving and medical transportation. She also feels that Mr. Finch is not eating well and noted that he has lost 15 pounds over the last few months. The client’s medications include Aspirin 325 milligrams by mouth every day, Atenolol 100 milligrams by mouth every day, Atorvastatin 60 mg by mouth every day, Calcium Acetate 2668 milligrams with each meal day, Metformin 2000 milligrams by mouth every day, Gabapentin 500 milligrams by mouth four times a Case Management Initiatives for Enrollees in MA Programs 39 day, and Lorazepam 0.5 mg by mouth as needed every four hours. The client is compliant in taking his medication and completing his dialysis treatments. Table 7 Recommended assessments and interventions for Mr. John Finch Assessment Name Assessment Use Assessment of John Finch Geriatric Intake Assessment Initial assessment tool to John notes that his health is quickly identify areas that are poor and is experiencing pain found to be irregular or need in his left leg surgical site. He further investigation states that he can hear "fine." He notes that he is having difficulty dressing his lower body post-operatively. He also states that he “can’t remember like I use to” and has not received a pneumonia shot. His wife has mentioned how John has lost weight. Cognitive impairment is noted with a mini-cognitive test. Based on this assessment, an AD8, ADLIADL, CAM, Chronic disease, Medicaid, and Posthospital discharge assessments should be completed. AD8 Assessment of cognitive AD8 assessment determines status and level of that John is experiencing mild functionality cognitive and/or memory impairment. John’s wife is also assessed for caregiver needs. The assessment helps establish collaborative care, follow up with community resources, and provides a clinical pathway for referrals. Activities of daily living and Assessment of activities of Post-surgery, John will need instrumental activities of daily living and instrumental more assistance with his daily living (ADL-IADL) activities of daily living ADLs and IADLs. The Assessment assessment identifies any needs for referral, a collaboration of care, accessing community resources, disease management, addressing caregiver needs, and Case Management Initiatives for Enrollees in MA Programs Caregiver Activation Measure (CAM) Assessment of caregiver Chronic disease assessments, including Chronic Kidney Disease-End Stage Renal Disease, Diabetes, Heart Failure, HIV, Sickle Cell, Rheumatoid Arthritis. Assessment of disease history and management of chronic disease Medicaid Assessment of Medicaid qualification 40 providing teaching and education regarding illness/disease trajectory. Assessment of John’s wife, Julia, for caregiver strain and depression. The assessment also includes questions on how well the caregiver understands illness/disease management for individuals receiving care, prescribed medications, and community resources utilization. Case management activities may include referral to community resources, teaching/education of chronic illness, social work to assist with financial counseling and Medicaid application, and counselor referral for mental health. John should be assessed with Chronic Kidney Disease-End Stage Renal Disease, Diabetes Assessment, and Heart Failure Assessment. After assessing disease history and management of disease, interventions include follow up with a provider, education on disease trajectory, medication reconciliation and management, caregiver assistance, a collaboration of care, and access to community resources. The case manager also helps to establish a care plan with mutually defined care goals with John and Julia. John may be dually eligible for Medicare Advantage and Medicaid. The assessment helps to determine if he may qualify for Medicaid. Case 41 Case Management Initiatives for Enrollees in MA Programs Post-discharge from hospital Assessment of health after a hospital stay and follow up needs management provides a referral to social work to assist John with the Medicaid application process. Follow up with John after discharge from the hospital to determine health status and post-discharge health needs. Discharge needs may include home health, care collaboration, setting appointments with providers for clients, accessing community services, and teaching/education of chronic disease or illness. This case study example demonstrates how a referral for risk assessment follows the workflow path for inpatient to post-hospital discharge. The use of the Geriatric Health Questionnaire (Appendix 7) provides a quick summary and allows for a case manager to follow up in areas with a more in-depth assessment. The Geriatric Health Questionnaire identified that an AD8, ADL-IADL, CAM, Chronic disease, Medicaid, and Post-hospital discharge assessments should be completed. For example, conducting a mini-cognitive three-word test has been found by researchers to be a predictive indicator of dementia (Borson, Scanlan, Chen & Ganguli, 2003). Using the Geriatric Health Questionnaire and GCM, a case manager then follows up with the AD8 to further investigate the care-level needs and interventions required. Interviews with the clinical operations supervisor, the nursing professional development practitioner (nurse educator), the MA plan administration, and the supervisor case management were included to provide a collaboration of all stakeholders involved with MA program implementation. These interviews explored the needs of the MA population and departments Case Management Initiatives for Enrollees in MA Programs 42 involved with a new MA program. Likewise, a requested learning module can teach case managers about MA and recommended assessments and geriatric-specific interventions. An analysis of current practice and workflow demonstrated how a comprehensive assessment with new geriatric-specific assessment tools, like the Geriatric Health Questionnaire, can be incorporated to address MA enrollees' needs. A comparison of recommended assessment to current assessments utilized in practice provided a better understanding of what assessment tools and other suggested components should be integrated into existing practice. 4. Discussion With an aging US population, more individuals are living with chronic conditions and disabilities, and the risk of additional comorbidities with complexity to care increases. Older adults with multiple chronic conditions are at increased risk of being either overdiagnosed or underdiagnosed, which can impact their overall health and available resources (Bouchardy et al., 2007). Furthermore, Kenis et al. (2013) found that undertreatment can lead to worsening health and decreased functionality. Enrollees of a new MA plan and payor providers who utilize case management with a chronic care model, like GCM, can have improved health outcomes and care delivery (Boyd et al., 2010). An examination of how GCM should be integrated into an existing care management practice and what the expected outcomes for MA enrollees, providers, and payors will be discussed. Implications of a synthesized MA program at a practice and professional development level and a health policy level are also presented. 4.1 Integration and Outcomes GCM has demonstrated success and history by improving patients' and their caregivers' perception of the quality of chronic illness care (Boyd et al., 2010); (Wolff et al., 2010). Boult et al. (2013) also noted that outcomes for care included increased quality of life and decreased Case Management Initiatives for Enrollees in MA Programs 43 home care utilization for participants within a thirty-two-month study with MA, traditional Medicare, and Tricare plan enrollees using GCM. Because the population examined within this study (2013) is similar in characteristics and health to the new enrollees of the MA program for this healthcare provider, the expected outcomes should be the same; MA enrollees should also expect to experience a better quality of life, and decreased home health utilization. GCM is recommended as a chronic care model for the new MA program within this project. While investigating the current practice, the supervisor case manager revealed that case management does not have a formal care model but uses chronic care elements. While not formally identified, case management utilizes all the recommended aspects of the GCM, including assessment planning, chronic disease self-management, a collaboration of care, coaching, monitoring, and community resource utilization. As a result, many of the same patient, provider, and overall health system outcomes can be expected for the new enrollees of the MA program for this healthcare provider. Moreover, Thorpe et al. (2015) noted that individuals with a chronic illness might be inadequately informed and unprepared for future care needs and long-term care planning. Kremenchutzky (2013) found that providers may also have an incomplete understanding of their patient's perception of their chronic illness, which contributes to insufficient long-term planning. GCM overcomes the uncertainty of chronic illness by improving communication between providers and their patients (Masteller, 2010). Communication is increased through collaborative care and increased provider knowledge about a chronically ill patient (Marsteller, 2010). Electronic charting, which is completed by case managers and providers, also enhances communication. Electronic charting enables case managers to monitor their client's health status and complete care planning. Additionally, patients have access to their medical information Case Management Initiatives for Enrollees in MA Programs 44 online through the MA plan website. Case managers can also assist in preparing enrollees with long-term planning and advanced care with current assessments in place. With the known outcome of improved communication, MA payors, providers, and enrollees can expect decreased uncertainty of disease trajectory with collaborative care. In addition to the GCM, Ekdahl et al. (2016) found that comprehensive geriatric assessment-based care can reduce hospitalization and increase survival for older adults. Participants of this study (2016) were similar to the enrollees who will be signing up for the new MA plan in age and comorbidities. Additionally, costs were not significantly increased with a comprehensive geriatric assessment, at $1,350 per participant. The GCM with comprehensive geriatric assessments and US Preventative Services Task Force recommendations (Table 3) may provide the same outcomes as noted within the study (2016) for enrollees and MA payors. MA enrollees can expect outcomes of fewer days of hospitalization and increased survivorship. Furthermore, it can be expected that the new MA program's cost will be similar for providers and payors. 4.2 Implications for Practice and Professional Development As an integrated and synthesized model for case management, this paper demonstrates how the GCM can be used to impact patient and systems-related outcomes of care by case managers in payors and providers roles in a MA setting. The supervisor case manager noted that once individuals became clients of case management, they really appreciate the advocacy and personalized care plan. Additionally, the GCM can be tailored and integrated into current case management practice. For example, this healthcare provider from this project easily incorporated the Geriatric Health Questionnaire (Appendix 7) into their current assessments to provide a geriatric focus for their new MA enrollees. The workflow diagram (Figure 2) clarifies key Case Management Initiatives for Enrollees in MA Programs 45 working processes and identifies who performs what activities and tasks. As noted by the Department of Health and Human Services (n.d.), a work flowchart provides visualization of a workflow by showing the sequence and interactions of steps, decisions, and activities involved. Following recommendations on workflow analysis from the Department of Health and Human Services (n.d.), the case management workflow assessment illustrated within this paper provides a visual workflow that can be tailored for case management within the payor and provider sides of Medicare. As of 2014, almost 30% of older adults who qualify for Medicare are choosing MA plans (Starc, 2014). With many enrollees switching from traditional Medicare to MA, case managers need to understand what MA is and how it is different from traditional Medicare. This paper provides a comprehensive examination of the population that MA serves and an in-depth analysis of the GCM and geriatric initiatives for case management. A learning module is also presented to train case managers on Medicare Advantage and how to utilize the recommended comprehensive geriatric assessment interventions with a case study. The workflow chart also exhibits the sequences and steps for inpatient and outpatient workflow to demonstrate how case management works through the decisions, steps, and activities of case management. An educated workforce is essential to support these MA enrollees with their chronic illnesses and maximize the benefits found within MA. The learning module and case study can assist case managers in practice and provide professional development to meet the growth and healthcare needs of MA enrollees. 4.3 Implications for Health Policy As described in this paper, traditional Medicare and MA are part of a national health insurance benefit program for older adults and other individuals who are disabled or have Case Management Initiatives for Enrollees in MA Programs 46 specific diseases (Wacker & Roberto, 2019). Traditional Medicare and MA have different types of payment structures for providers. Traditional Medicare is a fee-for-service program, and providers are paid on the volume of service. Additionally, enrollees of Medicare Part B have deductibles of 20% with no out-of-pocket maximum. For an older adult on a fixed income, which is noted by Cubanski et al. (2018), to be $26,000, coverage of these out-of-pocket costs can be financially devastating. In contrast, MA charges enrollees on a per month per member basis, and the out-ofpocket cost is set with maximum limits. The Kaiser Family Foundation (2019) examined when enrollees switched from traditional Medicare to a MA program, and enrollees saved an average of $1,253 in healthcare spending. Within this same study (2019), it was found that spending for MA enrollees was set at traditional Medicare spending levels, which may systematically overestimate expected healthcare costs. By adjusting payments to an MA enrollees' prior year of healthcare spending, Medicare spending could be lowered and could potentially reduce overall Medicare spending by billions of dollars annually. MA programs also offer expanded coverage beyond traditional Medicare through added dental and SilverFit programs. MA is rapidly growing and will provide coverage for more than 47% of individuals who are eligible for Medicare by 2029 (Congressional Budget Office, 2019). The Center for Medicare and Medicaid (2020) noted that 78% of MA enrollees also participate in high-quality programs with a 4-5-star rating. Higher rated MA programs are designed to drive quality value outcomes by incentivizing payors and providers. MA plan providers will receive monetary incentives for increased cost-effectiveness and for offering higher-quality plans with a 4-5-star rating (Wacker & Roberto, 2019). Mandal et al. (2017) noted that for enrollees of the capitated MA plan, emergency department visits, and inpatient hospital admission decreased, which saved the Case Management Initiatives for Enrollees in MA Programs 47 capitated MA plan $2,071,293 per 1,000 enrollees. Additionally, office-based care was increased for these capitated MA plan enrollees, which resulted in a 6% survival benefit and lowered the hazard of death by 32.8%. Ultimately, this study (2017) demonstrated that all of the capitated MA program stakeholders can benefit from a value-based outcome model. With the expanding growth of MA programs, savings potential exists at the individual and national level. Switching from traditional Medicare to MA is a move towards value-driven outcomes not usually embedded within traditional Medicare. MA programs can also provide better chronic illness management with expanded supplemental coverage and ultimately reduce overall healthcare spending. Overall, MA programs may be another component to help reduce the rapidly rising healthcare cost within the US. Ongoing research is needed to understand the impact of MA on overall care and healthcare costs in the future for the millions of people enrolled in Medicare. Research can focus on how training case managers in MA with geriatric assessments and initiatives can affect Medicare costs and functionality in the older adult population. Other research can focus on why MA is increasing, and whether it is the result of expanded coverage of supplemental plans. Furthermore, research can also examine how the CMS star rating system can incorporate geriatric initiatives to improve existing MA programs. 5. Conclusion With many older adults transitioning from traditional Medicare to MA over the next decade, MA can potentially save billions of dollars in the cost of care while also providing valuedriven outcomes. The literature review demonstrates why the cost-effectiveness of MA programs with best practices for care management models is needed to meet these patient-and systemsrelated outcomes of care. The healthcare workforce, payors, and other stakeholders need to be Case Management Initiatives for Enrollees in MA Programs 48 educated about the differences between traditional Medicare versus MA to better address the needs of MA enrollees, such as those with multiple comorbidities. Training case managers to use a chronic care model, like GCM, with geriatric initiatives can potentially reduce unnecessary health complications and also address unmet healthcare needs for MA enrollees. Likewise, GCM employs more effective communication between providers and payors, thus increasing valuedriven outcomes of care results in the future. The contained theoretical foundations, proposed interventions, and geriatric assessments are presented with the higher purpose of enabling MA programs enrollees to remain within their homes and communities, decrease their risk of the implications of comorbidities, and in due course, lower healthcare costs and burdens for enrollees and society. Individuals ultimately do better when surrounded by their loved ones and immediate support network, and the MA program will make this a realistic option for more and more individuals. Case Management Initiatives for Enrollees in MA Programs 49 References Aronson, L., Bautista, C., & Covinsky, K. 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Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-b-virusinfection-screening Case Management Initiatives for Enrollees in MA Programs 60 U.S. Preventative Services Taskforce. (25 September 2014). Lung cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancerscreening Vasquez, M. J., Garcel, J.M., Ward, E. A., & Rodriguez, L.J. (2018) Vulnerable populations: Meeting the health needs of populations facing inequities. In J. R. Knickman, A. R. Kovner & S. Jonas (Eds). Health care delivery in the United States (12th ed., pp. 183220). New York, NY: Springer. Wacker, R. & Roberto, K. (2019). Health and wellness. Community resources for older adults (5th ed, pp. 231-274). Thousand Oaks, CA: Sage Publication, Inc. Wolff, J. L., Giovannetti, E. R., Boyd, C. M., Reider, L., Palmer, S., Scharfstein, D., Marsteller, J., Wegener, S. T., Frey, K., Leff, B., Frick, K. D., & Boult, C. (2010). Effects of guided care on family caregivers. The Gerontologist, 50(4), 459–470. https://doi.org/10.1093/geront/gnp124 Case Management Initiatives for Enrollees in MA Programs Appendix Appendix 1: Guided Care Model (Boyd et al., 2007) 61 Case Management Initiatives for Enrollees in MA Programs Appendix 2: Geriatric Depression Scale (Sheikh & Yesavage, 1986) 62 Case Management Initiatives for Enrollees in MA Programs 63 Appendix 3: CAGE Questionnaire CAGE Questions* 1. Have you ever felt you needed to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking? 3. Have you ever felt Guilty about drinking? 4. Have you ever felt you needed a drink in the morning (Eye-opener) to steady your nerves or get rid of a hangover? *Two or more positive answers are considered to be a positive screen. (Liskow, Campbell, Nickel & Powell, 1995) Case Management Initiatives for Enrollees in MA Programs Appendix 4: Katz Index of Independence in Activities of Daily Living (Katz, 1983) 64 Case Management Initiatives for Enrollees in MA Programs Appendix 5: Lawton-Brody Instrumental Activities of Daily Living (IADL) Scale 65 Case Management Initiatives for Enrollees in MA Programs (Lawton & Brody, 1969) 66 Case Management Initiatives for Enrollees in MA Programs 67 Appendix 6: Learning Module Mockup CASE MANAGEMENT INITIATIVES FOR ENROLLEES OF MEDICARE ADVANTAGE PROGRAMS __________________________________________________________ Created by Sherrie M. Harding, RN, BSN, GIP Master’s Student Case Management Initiatives for Enrollees in MA Programs 68 LEARNING OBJECTIVES • Describe Traditional Medicare versus Medicare Advantage (MA) • Understand the costs of MA • Understand the quality of MA plans as measured by the Center for Medicare/Medicaid Services (CMS) • Populations served by MA • Description of MA Program • Case management workflow • Case management for MA and geriatric assessments and interventions Case Management Initiatives for Enrollees in MA Programs 69 TRADITIONAL MEDICARE VERSUS MEDICARE ADVANTAGE Traditional Medicare Medicare Advantage Medicare A-Hospital Services Medicare Advantage-covers Medicare B-Outpatient Services • Premium of $144.60 Hospital and Outpatient Services Fee for service Payment per month, per member basis • Base Premium of $144.60 from Part B applied to the monthly enrollment fee Coverage across the country Use hospitals and providers within the medical/provider health system No out of pocket maximum for physician services Maximum out-of-pocket cost for in network-and out-of-network Script states: According to the CMS, there are over 63.2 million people on Medicare. It is a national health insurance program, and to be eligible for any Medicare benefit plan, an individual must also qualify for Social Security or Railroad Retirement benefit. Enrollees are typically aged 65 and over. Medicare is also offered to enrollees who are under age 65 if they are experiencing end-stage kidney disease requiring dialysis or transplant, or have been disabled for twenty-four months or longer or have Lou Gehrig’s disease. With traditional Medicare, there are two components: Part A for inpatient and Part B for outpatient services. Traditional Medical provides coverage across the country, in a fee for service-open system program. There is significant cost-sharing, $1,216 for hospital services, and 20% for Part B outof-pocket cost. There are no out of pocket max for physician services. Enrollees can purchase supplemental plans called Medigap policies to offset the out of pocket charges. With Medicare Advantage (MA), it started out in the 1980’s Part C and was changed to Medicare Advantage. The Center for Medicare and Medicaid Services estimate that MA will grow by 47% by 2029. MA has payments on per month per member and use hospitals/providers within the health system. Part B premiums of $144.60 are applied for the monthly membership charge. References for this page include: (Wacker & Roberto, 2019) (Cubanski et al., 2018)(Center for Medicare and Medicaid, 2020) Case Management Initiatives for Enrollees in MA Programs 70 TRADITIONAL MEDICARE VERSUS MEDICARE ADVANTAGE COST Script states: Kaiser Family Foundation found that when enrollees switched to MA, they saved around $1,253. For an older adult on a fixed income of $26,000/year, this is a significant savings. Additionally, setting MA payments to providers at traditional Medicare levels may systematically overestimate the expected cost of MA enrollees. Adjusting Medicare payment to providers to reflect MA enrollees' prior use of health services could potentially lower overall Medicare spending by billions of dollars annually. Reference for this page includes: (Kaiser Family Foundation, 2019) Case Management Initiatives for Enrollees in MA Programs 71 QUALITY OF MA PLANS MEASURE BY CMS ▪ Star rating system by CMS ▪ Reviewed annually for CMS ▪ 78% of MA enrollees are in higher quality plans (4-5 Stars) Script states: The quality of MA plans is regulated by CMS. The star scale ranges from one to five stars, with a one-star rating for the lowest ratings to five stars for best performance. The star rating system helps consumers to shop for MA plans in their areas. MA overall plan's star rating is determined by five domains, which include staying healthy, chronic illness management, consumer experience with the plan, consumer complaints about the plan, and changes in MA plan performance. CMS annually reviews the five domains with feedback from clinicians and other stakeholders of the plan and verifies the reliability of plan measures (CMS, 2019). With a higher star rating quality, MA plan providers will receive monetary incentives for increased cost-effectiveness and for offering higherquality plans with a 4-5-star rating (Wacker & Roberto, 2019). In addition to rewarding MA plan providers for higher quality and cost-effectiveness, the consumer is rewarded by having a lower premium than the normal $144.60 Part B premiums charged (Glazer & McGuire, 2017). 78% of MA enrollees participate in higher quality plans. References for this page include: (Center for Medicare and Medicaid Services, 2019) (Wacker & Roberto, 2019) (Freed, Damico & Neuman, 2020) (Glazer & McGuire, 2017) Case Management Initiatives for Enrollees in MA Programs 72 POPULATION THAT MEDICARE ADVANTAGE SERVES ▪ Multiple chronic conditions increase with age ▪ Leading chronic conditions: ▪ Hypertension ▪ Arthritis ▪ Heart disease ▪ Cancer ▪ Diabetes ▪ 5% of the population accounts for half of healthcare spending Script states: Getting back to the figure of 63.2 million people enrolled in Medicare, 52.9 million are 65 and older, and 8.5 million are disabled (CMS, 2020). Haber (2016) noted that multiple chronic conditions increase with age. Within this population, chronic conditions include hypertension, arthritis, heart disease, cancer, and diabetes. Also, noteworthy, 5% of the population accounts for half of the healthcare spending. This figure represents how we can do better is chronic care management and managing healthcare costs for this population. References for these figures on this page include: (Center for Medicare and Medicaid, 2020) (Haber, 2016) (Komaromy et al., 2018) (Bouchardy et al. 2007) Case Management Initiatives for Enrollees in MA Programs 73 DESCRIPTION OF MEDICARE ADVANTAGE PLAN • $0 premiums on select plans • $0 medical deductibles • Plans include basic vision and dental, or – enrollees can add more expanded coverage for these services as a supplemental • Coverage beyond traditional Medicare: – routine hearing exam and hearing aids • SilverFit Fitness Program Script states: This is a description of Regence’s MA PPO plan. Please modify this and adapt to your MA program benefit features. Case Management Initiatives for Enrollees in MA Programs 74 GUIDED CARE MODEL (GCM) ▪ Nurse case manager and 2-5 Primary Care Providers ▪ Seven concepts of Chronic care ▪ Disease management to geriatric evaluation ▪ Clinical Activities ▪ Assessment, chronic disease management, coaching ▪ Improved quality of life and decrease the use of home health Script states: This page is based upon a care model from my research but can be modified according to the care model in current use. This chronic care model is based on Boyd et al. (2007) research and has been implemented within eight health systems. The program incorporates the seven concepts of chronic care, including disease management, self-management, case management, lifestyle modification, transitional care, caregiver support and education, and geriatric evaluation and management. GCM has been noted to improve the quality of life for enrollees and decrease the use of home health. Clinical activities assessment (which includes activities of daily living, instrumental activities of daily living, depression, and cognitive status), planning, chronic disease management, monitoring, coaching, coordination of care, education, and support of enrollee and caregivers accessing community resources. References for this slide includes: (Boyd et al., 2007; Boult et al., 2013) Case Management Initiatives for Enrollees in MA Programs 75 GCM CONSIDERATIONS FOR ENROLLEES OF MEDICARE ADVANTAGE Script states: Medicare Advantage (MA) enrollee is at the center of a GCM. The GCM considers the enrollee's preferences and actions. Healthcare resources are utilized more efficiently for an enrollee within their given clinical state and setting. Coordination of care can assist in improving the quality of life, based upon best evidence-practice. Case Management Initiatives for Enrollees in MA Programs 76 WORKFLOW DIAGRAM FOR CASE MANAGEMENT Script states: Workflow assessment is used in case management (CM) practice. After a referral is provided to case management, the referral goes through a process step of inpatient or outpatient workflow path. Decision findings from the assessment determine the process steps of case management activities. Activities range from medication reconciliation to accessing community resources. Inpatient and outpatient workflows have defined time frames and may end when defined care goals have been met, or change occurs with insurance coverage or providers. Communication, collaboration, and coordination of care can also occur between both workflow paths for their clients. Case Management Initiatives for Enrollees in MA Programs 77 RECOMMENDED GERIATRIC INTERVENTIONS ▪ US Preventative Services Task Force (USPSTF) ▪ Independent panel of experts ▪ Provide recommendations on screening, counseling, and preventative topics Script states: US Preventative Services Task Force is an independent panel of experts that reviews all current studies and data. The task force makes recommendations on screening counseling and preventative topics. References for this slide include: (US Preventative Services Taskforce. Recommendations https://uspreventiveservicestaskforce.org/uspstf/recommendation-topics) Case Management Initiatives for Enrollees in MA Programs 78 GERIATRIC ASSESSMENT FORMS Script states: The assessment intake form, called the Geriatric Health Questionnaire, was created by the Iowa Geriatric Education Center (2020 and is recommended as an intake form that provides a quick review of all systems. The form incorporates questions of general health and pain. It also assesses how well individuals can complete their activities of daily living and instrumental activities of daily living. It then provides a general review of health systems from the bladder function to hearing and eyesight. The form also contains questions on alcohol use, advanced care directives, and caregiver needs, and preventive care. The final section of the form test memory and cognitive status with a mini-cognitive test of three words and a clock test. As an assessment tool, it provides a quick summary and allows for a case manager to follow up in areas with a more in-depth assessment. When areas are found to be irregular or need further investigation, case managers can utilize assessments like the AD8 or ADL-IADL found within the case assessment guide. For example, conducting a mini-cognitive three-word test has been found by researchers to be a predictive indicator of dementia. The case manager can then follow up with the AD8 to further investigate the care-level needs and interventions required. Reference for this page includes: (Iowa Geriatric Education Center, 2020) Case Management Initiatives for Enrollees in MA Programs 79 CASE STUDY FOR GERIATRIC INTERVENTIONS For this slide present a case study that is applicable for case management to work through for new geriatric assessment and intervention process. Suggested case study: Example Case Study with Geriatric Assessments and Interventions Client information: Current Residence: Personal residence-233 East Main St. American Fork, UT 84003 Referral type: Risk assessment Client name: Mr. John Finch Gender: Male DOB & Age: July 12, 1948-Age 72 Marital status: Married Race: Caucasian Language: English Education: Bachelor’s in Education Code Status: DNR/Advanced Directives Client History: Mr. Finch was admitted to the hospital one week ago for having a “cold left leg” and non-healing left foot ulcer. He subsequently had to have emergency surgery to amputate his lower left leg, due to having no circulation (ischemic leg) in his left lower leg. When asked about his health and pain level, Mr. Finch states that his health is “generally poor” “and is “in constant pain” at his left leg stump surgical site. The client has an 8-year history of type 2 diabetes, underwent a coronary artery bypass five years ago, has end stage kidney disease, and has a right arm arteriovenous fistula. The client also experiences anxiety. The client receives hemodialysis three times a week, and his wife drives him to all of his dialysis appointments. Mr. Finch lives at home with his wife, Julia Finch, in American Fork, where they have lived for the last 32 years. The client is oriented to familiar surroundings but recently started to experience cognitive decline. Before his lower left leg amputation, he was able to ambulate with a walker. He is generally independent with his activities of daily living. He can dress his upper and lower body but needs stand-by assistance while bathing. He can no longer manage his finances. Mrs. Finch is anxious about being able to drive her husband to and from dialysis now with his amputated limb. She would also like to know what community services are available for caregiving and medical transportation. She also feels that Mr. Finch is not eating well, and noted that he has lost 15 pounds over the last few months. Case Management Initiatives for Enrollees in MA Programs 80 The client’s medications include Aspirin 325 milligrams by mouth every day, Atenolol 100 milligrams by mouth every day, Atorvastatin 60 mg by mouth every day, Calcium Acetate 2668 milligrams with each meal every day, Metformin 2000 milligrams by mouth every day, Gabapentin 500 milligrams by mouth four times a day, and Lorazepam 0.5 mg by mouth as needed every four hours. The client is compliant in taking his medication and going to his dialysis treatments. Case Management Initiatives for Enrollees in MA Programs 81 CASE STUDY FOR GERIATRIC INTERVENTIONS ASSESSMENTS ______________________________________________________________________________ Table 8 Recommended assessments and interventions for Mr. John Finch Assessment Name Assessment Use Assessment of John Finch Geriatric Intake Assessment Initial assessment tool to John notes that his health is quickly identify areas that are poor and is experiencing pain found to be irregular or need in his left leg surgical site. He further investigation states that he can hear "fine." He notes that he is having difficulty dressing his lower body post-operatively. He also states that he “can’t remember like I use to” and has not received a pneumonia shot. His wife has mentioned how John has lost weight. Cognitive impairment is noted with a mini-cognitive test. Based on this assessment, an AD8, ADLIADL, CAM, Chronic disease, Medicaid, and Posthospital discharge assessments should be completed. AD8 Assessment of cognitive AD8 assessment determines status and level of that John is experiencing mild functionality cognitive and/or memory impairment. John’s wife is also assessed for caregiver needs. The assessment helps establish collaborative care, follow up with community resources, and provides a clinical pathway for referrals. Activities of daily living and Assessment of activities of Post-surgery, John will need instrumental activities of daily living and instrumental more assistance with his daily living (ADL-IADL) activities of daily living ADLs and IADLs. The Assessment assessment identifies any needs for referral, a collaboration of care, accessing community resources, disease Case Management Initiatives for Enrollees in MA Programs Caregiver Activation Measure (CAM) Assessment of caregiver Chronic disease assessments, including Chronic Kidney Disease-End Stage Renal Disease, Diabetes, Heart Failure, HIV, Sickle Cell, Rheumatoid Arthritis. Assessment of disease history and management of chronic disease Medicaid Assessment of Medicaid qualification 82 management, addressing caregiver needs, and providing teaching and education regarding illness/disease trajectory. Assessment of John’s wife, Julia, for caregiver strain and depression. The assessment also includes questions on how well the caregiver understands illness/disease management for individuals receiving care, prescribed medications, and community resources utilization. Case management activities may include referral to community resources, teaching/education of chronic illness, social work to assist with financial counseling and Medicaid application, and counselor referral for mental health. John should be assessed with Chronic Kidney Disease-End Stage Renal Disease, Diabetes Assessment, and Heart Failure Assessment. After assessing disease history and management of disease, interventions include follow up with a provider, education on disease trajectory, medication reconciliation and management, caregiver assistance, a collaboration of care, and access to community resources. The case manager also helps to establish a care plan with mutually defined care goals with John and Julia. John may be dually eligible for Medicare Advantage and Medicaid. The assessment 83 Case Management Initiatives for Enrollees in MA Programs Post-discharge from hospital Assessment of health after a hospital stay and follow up needs helps to determine if he may qualify for Medicaid. Case management provides a referral to social work to assist John with the Medicaid application process. Follow up with John after discharge from the hospital to determine health status and post-discharge health needs. Discharge needs may include home health, care collaboration, setting appointments with providers for clients, accessing community services, and teaching/education of chronic disease or illness. Script states: After the referral is received from risk assessment, the case manager will follow the workflow for inpatient referral and follow steps and case management activities for this. The use of the Geriatric Health Questionnaire, a geriatric assessment form, provides a quick summary and allows for a case manager to follow up in areas with a more in-depth assessment. The Geriatric Health Questionnaire identified that an AD8, ADL-IADL, CAM, Chronic disease, Medicaid, and Post-hospital discharge assessments should be completed. For example, conducting a mini-cognitive three-word test has been found by researchers to be a predictive indicator of dementia. The case manager can then follow up with the AD8 to further investigate the care-level needs and interventions required. Case Management Initiatives for Enrollees in MA Programs 84 REFERENCES Bouchardy, C., Rapiti, E., Blagojevic, S., Vlatos, A., & Vlatos, G. (2007). Older female cancer patients: Importance, causes, and consequences of undertreatment. Journal of Clinical Oncology, 25(14), 1858–1869. DOI:10.1200/JCO.2006.10.4208 Boult, C., Leff, B., Boyd, C. M., Wolff, J. L., Marsteller, J. A., Frick, K. D., Wegener, S., Reider, L., Frey, K., Mroz, T. M., Karm, L., & Scharfstein, D. O. (2013). A matched-pair clusterrandomized trial of guided care for high-risk older patients. Journal of general internal medicine, 28(5), 612–621. DOI: 10.1007/s11606-012-2287-y Boyd, C., Boult, C., Shadmi, E., Leff B., Brager, R., Dunbar, L., Wolff, J.L., Wegener, S. (2007). Guided Care for Multimorbid Older Adults. The Gerontologist, 47(5), 697–704. Center for Medicare and Medicaid Services. (February 2020). CMS February 2020 fast facts. Retrieved from file:///C:/Users/scmha/AppData/Local/Temp/Temp1_CMSFastFactFebruary2020%20(1). zip/CMSFastFactFebruary2020.pdf Center for Medicare and Medicaid Services. (9 October 2019). Fact sheet-2020 Part C and D star ratings. Retrieved from https://www.cms.gov/Medicare/Prescription-DrugCoverage/PrescriptionDrugCovGenIn/Downloads/2020-Star-Ratings-Fact-Sheet-.pdf CREATING HIGH-QUALITY RESULTS AND OUTCOMES NECESSARY TO IMPROVE CHRONIC (CHRONIC) CARE ACT OF 2017, SB 870,115th. (2017). Retrieved from https://www.congress.gov/bill/115th-congress/senate-bill/870 Cubanski, J., Neuman, T., Daminco, A., & Smith, K.E. (2018). Medicare beneficiaries’ out-ofpocket health care spending as a share of income now and projections for the future. Henry J. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/Report-Medicare-Beneficiaries-Out-of-Pocket-HealthCare-Spending-as-a-Share-of-Income-Now-and-Projections-for-the-Future Freed, M., Daminco, A., & Neuman, T. (22 April 2020). A dozen facts about Medicare Advantage in 2020. Kaiser Family Foundation. Retrieved from https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage-in2020/ Iowa Geriatric Education Center (2020). Geriatric health questionnaire. Retrieved from https://igec.uiowa.edu/sites/igec.uiowa.edu/files/tools/function/geriatric_health_questionn aire.pdf Kaiser Family Foundation. (7 May 2019). Beneficiaries who switch to Medicare Advantage have lower Medicare spending and use fewer services in the prior year than those who stay in traditional Medicare-Current Medicare Advantage payment system may overestimate expected costs for plans. Retrieved from https://www.kff.org/health-costs/pressrelease/beneficiaries-who-switch-to-medicare-advantage-have-lower-medicare-spendingand-use-fewer-services-in-prior-year-than-those-who-stay-in-traditional-medicare/ Case Management Initiatives for Enrollees in MA Programs 85 REFERENCES Wacker, R. & Roberto, K. (2019). Health and wellness. Community resources for older adults (5th ed., pp. 231-274). Thousand Oaks, CA: Sage Publication, Inc. Case Management Initiatives for Enrollees in MA Programs Appendix 7: Geriatric Health Questionnaire 86 Case Management Initiatives for Enrollees in MA Programs (Iowa Geriatric Center, 2020) 87 88 Care Management Program for Enrollees in MA Programs Appendix 8: Workflow Assessment of Team Roles and Task Distribution MA Communication with patients, outside of patient office visit Answer phones, triage calls Help manage/triage provider electronic inbox Serve as primary point of contact for patients Conduct patient outreach for outstanding labs, etc. Follow-up by phone or email after visits to make sure that patient understood instructions Follow-up with patients after hospital discharge Follow-up with patients after Emergency Department visit Respond to patient calls requiring clinical assessment and decision-making Community-based efforts to connect new patients to the practice Notify patients about normal lab results Notify patients about abnormal lab results Preparation for patient visits and proactive population management Pre-visit planning/chart scrubbing Conduct patient outreach for outstanding labs, etc. Independent visit to prepare patients for a provider visit Participate in care team huddles to review the plan for the day Participate in regular meetings to review outcomes for patients who have not yet reached chronic disease-related clinical goals Participate in regular meetings to review outcomes for patients who have not yet health-related clinical goals Patient visit tasks Perform injections Reconcile medications Scribe for providers EKGs Spirometry RN Lay person PharmD Case Manager No one x X x x x x x x x x x x x x x x x x x x X X x x x x x X x x x x x x x x x X X X X Other 89 Care Management Program for Enrollees in MA Programs Assist with basic procedures Conduct well visits (with provider oversight) Conduct preventive care visits (with provider oversight) Patient education, coaching, and care management Perform "teach-back" with the patient at the end of the visit Orient new patients to the practice Develop care plans with the patient Help address barriers to patient goals Health coaching and motivational interviewing Patient health education Conduct group visits Conduct home visits Complex care management Medication titration, by protocol Run patient support groups Meet with patients about concerns or resistance with taking medications Conduct thorough medication reviews with patients Provide self-management support to patients Screen patients for depression and other chronic mental health disorders Screen patients for substance use disorders Administrative and Quality Improvement Participate in quality improvement and practice improvement activities Lead quality and practice improvement activities Coordinate/track outgoing referrals Close the loop on referrals (consult notes from the specialist have been received and added to our EHR) Administrative tasks around medication refills, labs, imaging Pre-authorizations Check patients in Check patients out Generate exception reports or registries in order to conduct population management/outreach Generate team-level QI reports X X X x x x x x x x x x x x x x x x x x x X X x x x x x x x x x x x x x x x x x X X x x X X x x x x 90 Care Management Program for Enrollees in MA Programs Supervise and support Mas Lead the care team Other services Run specialized care services, such as programs for obstetric patients or Coumadin patients Connect patients to resources in the community Help patients navigate the health care system. Consult providers and clinical staff on medication use and dosing Provide brief or short-term counseling for patients coping with an episodic behavioral health concern Consult with providers on evidence-based treatment for depression, anxiety, or bipolar disorders Other tasks: Other tasks: Other tasks: Other tasks: Other tasks: (Robert Wood Foundation, 2020) x x x x x x x x x x x x x Care Management Program for Enrollees in MA Programs Table of Evidence 91