To meet the complex medical, social and functional needs of the nation's estimated 9 million dually eligible, more than two-thirds of organizations surveyed in 2013 identified community support as essential to care coordination of Medicare-Medicaid beneficiaries.

CMS' state demonstrations to integrate duals' care also emphasizes home- and community-based services.

The philosophy that healthcare is local — and therefore, care needs to be local and community-based — drives WellCare Health Plans’ efforts to connect its dually eligible population to health services.

Community Care Connections for Dual Eligibles: Closing Social Gaps to Improve Health Outcomes details the WellCare approach to duals' care coordination — a healthy mix of public health and social support in which a team of advocates works the front lines of the community, cataloging and pooling resources with a common goal — the reopening of a local food bank, for example.

In this 27-page report, Pamme Taylor, WellCare's vice president of advocacy and community-based programs, shares the Tampa-based healthcare company's culturally competent approach to assessing duals' unique personal circumstances, ensuring their 'soft landing' into WellCare’s care coordination system.

Care managers at the heart of WellCare's multidisciplinary team conduct a comprehensive needs assessment with each Medicare-Medicaid beneficiary and engage community resources in the resulting care plan.

WellCare's approach helps to ensure that duals' complex care needs are met at the most appropriate time and level.

Using the example of an extended family to demonstrate benefits from the HealthConnections program, Ms. Taylor provides details on WellCare's approach to the following:

• Connecting with primary care physicians and specialists to assess member needs;
• Using PCPs and specialists to identify cultural and ethnic preferences to improve member engagement;
• Developing a referral tracking system embedded in the electronic health record for case managers to link members to available services;
• Expanding the referral tracking system data inputs to create a truly population health-focused platform; and
• Working with community-based programs with constrained budgets to sustain needed services for their members.

Care coordination of dual eligibles has been identified as one of the top 10 healthcare priorities for 2013 by PricewaterhouseCoopers LLP.

Table of Contents

• Closing Duals; Care Gaps and Engaging Members in Self-Management
  • HealthConnections Model of Care
  • Four Socially Based Care Gaps
  • Impact of Federal Funding
  • Connecting Community-based Programs and Social Supports
  • Community Advocates and Health Needs Assessments
  • HealthConnections Pilot Results
  • WellCare's Community Service Database
  • Program Evaluation
• Q&A: Ask the Experts
  • Contact and Follow-Through with Duals
  • Overcoming Communication Barriers
  • Assessing a Community's Service Needs
  • Components of the Duals Health Assessment
  • Defining the Duals' 'Soft Landing'
  • Hiring and Training Community Workers
  • 5 Roles of the Community-Based Worker
  • Evaluating Community-Based Programs
  • SNF's Role on the Interdisciplinary Team
  • Challenges of Coordinating Care for Dual Eligibles
  • Addressing LTC Needs
  • Care Manager's Role in HealthConnections
• Glossary
• For More Information
• About the Speakers