Coming Home and Staying There: Improving Care Transitions for Dually Eligible Beneficiaries

Webinars

Date and Time: December 12, 2019, 2:00 pm – 3:30 pm ET

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Improving transitions between care settings is critical to achieving positive health outcomes and enhanced quality of life, particularly for dually eligible beneficiaries navigating fragmented Medicare and Medicaid programs. Integrated care programs seek to better coordinate acute care and long-term services and supports (LTSS), which can support successful transitions from hospitals and nursing facilities to community settings, and reduce avoidable hospitalizations and institutional stays.

This webinar, made possible by The Commonwealth Fund, will explore innovative integrated health plan approaches to improve care transitions. Health plans featured in the webinar, which is cosponsored by the Center for Health Care Strategies (CHCS) and the Better Care Playbook, participate in Promoting Integrated Care for Dual Eligibles (PRIDE), a project to advance health plan strategies for providing high-quality care for dually eligible beneficiaries. During the webinar, three plans will describe their care transition approaches, including how they identify individuals in need of supports, work with delivery system and community-based partners, and address the needs of members with housing insecurity. Speakers will share program outcomes as well as lessons for health care stakeholders interested in improving care transitions for high-need populations.

Health plan and health system leaders, health care policymakers, state officials, and other interested stakeholders are invited to join this 90-minute event.


Agenda

I. Welcome and Introduction

Speakers: Logan Kelly, Senior Program Officer, CHCS and Tanya Shah, Vice President, Delivery System Reform, The Commonwealth Fund

L. Kelly and T. Shah will welcome participants and discuss the care coordination challenges faced by dually eligible beneficiaries as well as new opportunities to improve transitions across care settings.

II. iCare’s Follow to Home Program

Speaker: Lisa Holden, Vice President, Accountable Care, Independent Care (iCare) Health Plan

L. Holden will describe key elements and results from iCare’s Follow to Home program to improve care transitions and reduce readmissions. She will also discuss how the plan adapted the program to meet the needs of homeless members discharged from the hospital.

III. Health Plan of San Mateo’s Community Care Setting Program

Speaker: Amy Scribner, Director of Behavioral Health, Health Plan of San Mateo (HPSM)

A. Scribner will provide an overview of and results from HPSM’s Community Care Settings Program, which helps dually eligible members living in nursing facilities to transition to community settings.

IV. CareSource’s Care Management Model to Improve Care Transitions

Speakers: Jennifer Anadiotis, Director Integrated Care Post-Acute Strategy, and Jean Solomon, Director of Long Term Support Services, CareSource

J. Anadiotis and J. Solomon will provide an overview of the comprehensive care management model designed by CareSource to: (1) identify members living in nursing facilities who can successfully transition to the community; and (2) ensure access post-discharge to home- and community-based services and supports to help members stay at home.

V. Moderated Q&A

Moderator: Logan Kelly