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To locate, stratify and engage dual eligibles, Health Care Services Corporation (HCSC) takes a creative approach, employing everything from home visits to 'street case management' to coordinate care for Medicare-Medicaid beneficiaries.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population describes HCSC's innovative tactics to engage this largely older adult and disabled population in population health management with support from a range of community partners and services.

In this 25-page report, Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation, details HCSC's care coordination model for the dually eligible and some early program impacts, as well as lessons gleaned from 12 years of work with other plans serving duals.

From a kickoff health risk assessment (HRA) to risk-based care and service planning, Ms. Faulhaber describes how HCSC accomplishes the following:

• Stratifies, locates and engages dual eligible beneficiaries into care coordination efforts;
• Employs either a nurse-led or social worker-led care coordination strategy based on the unique needs of the population served;
• Supplements its own in-house care coordination resources with community-based services such as promotoras and tribal government;
• Applies 'street case management' to engage the homeless population;
• Employs unique models to serve the distinctly different needs of dual eligibles with physical or developmental disabilities;
• Integrates medical and behavioral health approaches for duals with serious mental illnesses; and
• Overcomes the roadblocks it has encountered in the dual eligible market.

Table of Contents

• Moving Beyond the Medical Care Coordination Model for Dual Eligibles
  • Strategies for Engagement of Duals
  • Outreach Collaborations
  • HRA and Risk Stratification
  • Service Planning
  • Care Coordination Teams and Ratios
  • Models of Care Coordination
  • Working with Beneficiaries with Disabilities
  • Integrating Behavioral and Medical Health Care
  • Outcomes from Minnesota Duals Programs
  • Overcoming Roadblocks to Duals Care Coordination
• Q&A: Ask the Experts
  • ‘Street’ Case Management in Identification of Homeless
  • Payment for Hospice Services
  • Minnesota CAHPS Measures
  • Structure of Homegrown HRA
  • HRA Completion Rate
  • Home Visits for Higher Risk Members
  • Screening for Behavioral Health Issues
  • Data Analytics for Enrollment and Care Coordination
  • Transportation Challenges for Duals
  • Options Beyond Telephonic Outreach
  • Bridging the Behavioral Health-Medical Care Gap
  • Conducting a Telephonic HRA
  • Collaborating with Medicaid
  • mHealth and Remote Monitoring with Duals
  • Cultural Sensitivity with Duals
• Glossary
• For More Information
• About the Presenter