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Simply leaving the home is terribly complicated for many frail and chronically ill people. Those who have difficulty walking or who need a wheelchair could find it takes months or years to navigate a healthcare system in which paying for personal equipment is challenging.
Social services and the healthcare system are so complex that even professionals can find the process frustrating, says Karen Bonner, CCM, RN, MBA, field manager for Post Acute Network Solutions in Rosemont, IL.
"It once took me two days to figure out how to get someone a seat cushion for their wheelchair," Bonner says.
Sometimes, case managers look at each other and ask how their clients could possibly manage on their own, she says. "How can they do this?" Bonner asks. "I tell members to call me because they don’t have to figure it out on their own; we can do it together."
Under the Affordable Care Act, there are demonstration projects and incentives to help bridge the gap between medical care and social services. Some states also have come up with strategies, such as Illinois’ Medicare-Medicaid Alignment Initiative (MAI), which provides a new model of coordinated, person-centered care for Medicare-Medicaid enrollees. The initiative launched in 2014.
Illinois also has a Medicaid waiver initiative, called the Supportive Living Program, that serves as an alternative to nursing home care for low-income people who are older or living with Medicaid-eligible disabilities. MAI services are available to people living at home, in nursing homes, or in supportive living facilities.
"In most states, Medicaid will pay for people to be custodial residents in a nursing home or skilled nursing facility," says Kathleen Miodonski, RN, BSN, CMAC, vice president of clinical operations at Post Acute Network Solutions.
"In Illinois, there was the thought that some people don’t need a nursing home because they have higher-level functioning, but they need some assistance," she says. "It’s like an assisted living facility, but Medicaid pays for it."
Supportive living facilities, which are called SLFs, are less expensive and promote some independence. Medicaid can pay for personal care, homemaking, laundry, medication supervision, social activities, and recreation.
"The supportive living facilities are more of a financial and social level of care," Miodonski says. "They can live there based on their level of need."
Residents typically are elderly people who are having difficulty keeping up with a household on their own. They no longer can drive or buy their own groceries. They do not need continuous nursing care, and they are able to handle some of their own daily care.
SLF populations are vulnerable and can have high hospitalization and emergency department visit rates, so they were an ideal place to focus some of the new MAI services, she says. Medicare contracts with companies to provide case management for care coordination. Called care coaches, these nurses handle up to 75 members, Miodonski says.
"The goal of our program is to decrease hospitalizations and coordinate care to keep these people as healthy and well as we can," she says.
Since the program is new, data on its success is not available. But anecdotal evidence suggests it’s working, Miodonski says.
"One of our care coaches early on talked with a lady who had gone out to get a hearing evaluation a year or more ago," she says. "They demonstrated she had hearing loss. But nobody did any follow-up to get her a hearing aid."
The care coach got involved and coordinated the benefit, she adds.
The MAI’s flexibility helps improve Medicaid members’ lives while providing better, more efficient medical care. (See story on MAI’s case management services, page 6.)
Before MAI, the SLFs were limited to what Medicaid could provide, and there was no case management.
"No one was there to coordinate the benefits. People would sleep there with their needs, and no one was there to address them," Miodonski says. "If someone needed to go to a doctor and the family was far away, then the person would just sit there and no one would monitor medication use."
Or, another common scenario might take place: A member would see two or three different doctors for similar problems and be treated by each.
In one case, a woman saw one doctor for her knee pain and another for her neck pain. It didn’t occur to her that one doctor could handle both problems, and each doctor prescribed medication without knowing about the other one, Bonner says.
"There is potential for polypharmacy and overprescribing of medications," she says. "We come in and see the whole picture, while before everything was so siloed."
Bonner offers a couple of examples of MAI members helped by the new program.
A young man with kidney disease. One member in his 20s had chronic kidney disease. While he tried to get on a waiting list for a kidney transplant, he was hindered by his inability to stay out of the hospital long enough to get bloodwork completed. Plus the young man could not leave his home because of mobility issues, Bonner says.
"Most of his peers are going to college, and he goes to dialysis," she adds.
Care coaching helped the man reduce his hospitalizations through psychosocial support. A care coach helped him improve his diet and sleep — both necessary to reducing his levels of stress. He had switched insurance previously and was unable to get a wheelchair, and this impacted his independence and quality of life.
"I helped him get a wheelchair and a bus pass. The last time I saw him, he said, I can go anywhere, do anything — I’ve got my freedom back,’" she says. "And a week or so ago, he had his pre-screening done to get on the transplant list."
An older woman with urinary tract infection. When an older woman developed a urinary tract infection, her doctor planned to send her to the hospital for IV antibiotics. The SLF staff called Bonner to ask for her help in keeping the woman at home, since that was what she desired.
"I went over there and talked with the doctor, who said, I’ve got a hospital bed for her, but I will give you a couple of hours to see what you can do. Otherwise, I will send her to the hospital,’" Bonner says.
"We made sure the antibiotics were delivered, and a home health agency helped set it up," she adds. "We made sure it was what she wanted, and the facility wanted to keep her home and it was set up in a couple of hours, so the doctor was comfortable with it."
The woman started the course of antibiotics while staying home in her apartment near her friends. There were no complications, and she was healed. "It was a win for everyone, and financially it was better," Bonner says.
Care coaches fill in gaps left by family members who are either not available or who are not able to help navigate social support systems or advocate for their loved ones.
"This is why case managers are going to be needed today and forever because the world of insurance and medicine is so complicated now," Bonner says.