Improving Care Coordination for Dual Eligibles with Long-Term Services and Supports | Harbage Consulting

Improving Care Coordination for Dual Eligibles with Long-Term Services and Supports

By Hilary Haycock, President and Lilly Clements, Junior Policy Consultant


Public programs are notoriously byzantine, and individuals who are trying to navigate across multiple public programs can face serious barriers to getting the care they need. California is one of 13 states operating a “duals demonstration” – or an initiative to provide more integrated care to individuals who have both Medicare and Medi-Cal (Medicaid in California) benefits (known as dual eligibles).

In California, this program is known as Cal MediConnect (CMC), which is part of the broader Coordinated Care Initiative (CCI) to better integrate long-term services and supports (LTSS) for dually eligible beneficiaries. LTSS includes a number of wrap-around services that help individuals live safely and more comfortably in the community – almost always at a lower cost to the overall system. For example, LTSS includes personal care services provided in the home to help with eating, bathing, and other daily activities. Effective LTSS integration can be a key determinant of quality of life for this population, as they are more likely to have complex medical needs and to be living with a disability. LTSS can help these members remain in their homes and their communities and avoid entering institutions like nursing facilities.

Based on several years of experience, evaluation findings indicate that, while CMC provides a valuable new pathway for serving dual eligible beneficiaries, more work can be done to effectively connect members to LTSS services and to better integrate and coordinate those services with the more traditional medical benefits that health plans offer.

As one of several initiatives to address this ongoing challenge, during the spring of 2018, Harbage Consulting worked with the California Department of Health Care Services (DHCS) and the federal Centers for Medicare & Medicaid Services (CMS) to facilitate a best practices process for Cal MediConnect plans. The goal was for the health plans to examine their own internal operations and share learnings with each other. DHCS recently released a summary and key findings from the best practices meetings.  Highlights from the report include:

Identifying LTSS Needs

  • CMC plans have implemented new standardized LTSS referral questions into their Health Risk Assessments (HRA). Having the plan conduct the HRA seems to accelerate the LTSS referral process and improve care coordination between providers and the care team.
  • Beyond the HRA process, plans are connecting with providers and beneficiaries while they are hospitalized in order to assess LTSS needs. The CMC plans have also developed systems to solicit referrals from internal departments and to encourage external referrals from members, caregivers, skilled nursing facilities (SNFs), community-based organizations (CBOs), and other programs.

Connecting Members to Services

  • The CMC plans are leveraging technology to support LTSS care coordination, including integrating the HRA into the electronic health record (EHR) so data is available across the care team. Care management software allows plans to use automatic reminders for care managers and providers to trigger follow-up.
  • For all types of referrals, plans are finding that it works best when care managers closely follow the referral process and when they work to build relationships with the LTSS providers.

Care Coordination Infrastructure:

  • How the CMC plans provide tailored care coordination to their members with LTSS varies; no single best practice has emerged, and each model has benefits and limitations in serving members. General best practices include:
    • Have a general care manager (non-clinical) conduct the initial follow-up and then assign an LCSW or LTSS trained care manager to provide follow-up on LTSS needs.
    • Integrate the care manager into the Interdisciplinary Care Team (ICT) and ensure referrals are reflected in the Individualized Care Plan (ICP).

Training and Education

  • Plans must train a wide variety of actors on LTSS services. Training should include information on what type of services are available, who is eligible, how to identify LTSS needs (and recognize when needs are urgent), how to connect members with LTSS, as well as resources in the community such as food, transportation, caregiver support, utility assistance, housing, etc.
  • In-service and orientation days at LTSS provider facilities can give staff the best understanding of how LTSS providers support their members.

Working with LTSS Partners

  • Several plans shared data with LTSS providers to help prevent unnecessary hospitalizations and emergency department visits.
  • The CMC plans have worked to build close relationships between care managers and LTSS program care managers to improve care delivery and coordination.

Download the full summary of the Cal MediConnect Best Practices process on