All Hands on Deck: How Commonwealth Care Alliance is Rethinking Protocol to Address COVID-19

By Lorie Martin, Center for Health Care Strategies

Across the country, health plans are responding to a new normal in the face of the pandemic currently overtaking the nation and the world. They are mobilizing efforts and changing business practices to ensure the health and safety of their members, particularly those with complex needs, and employees in addressing COVID-19. 

The Center for Health Care Strategies (CHCS) recently spoke with Lori Tishler, MD, MPH, Senior Vice President of Medical Services at Commonwealth Care Alliance (CCA) in Massachusetts, to learn how her organization is rethinking its day-to-day practice. CCA, which serves more than 36,000 individuals throughout Massachusetts, is a not-for-profit, community-based health care organization dedicated to improving care for people who are dually eligible for MassHealth (Medicaid) and Medicare with complex medical, behavioral health and social needs, including those with disabilities. Many of CCA’s members rely on home visits for ongoing care, necessitating a rapid rethinking of how to provide care in the current pandemic environment.

Q: What have you already put in place that is critical to supporting your members and providers right now in response to COVID-19?

A: We have had to move incredibly quickly — both in terms of how we take care of our members and our employees. Our focus: put people first and fulfill our mission to the individuals we so proudly serve. Right away we established frequent ongoing communication with our members, our provider network and our employed clinicians, along with our state and federal government partners.

In January, we implemented new clinical protocols to safeguard personal and public health; soon after, we activated our business-continuity plan. Business-continuity is of critical importance right now. We’re meeting internally twice a day — in the morning with the executive leadership team and with a larger team each afternoon representing four work streams: (1) clinical; (2) workforce; (3) operations; and (4) infrastructure/information technology.

We have a government relations team carefully monitoring and synthesizing key developments relevant to CCA — for example, the implications of Massachusetts’s 1135 waiver, federal lifting of some HIPAA rules, and use of video communication tools. This helps keep our clinicians as up-to-date as possible.

In addition to communicating with members with video, phone, and text messages, we have taken a number of actions to reduce member exposure and risk by helping them stay safe and independent at home. Our workforce also successfully transitioned to remote work last month with limited onsite activity only where required. This has been made possible by the continuing strength of our infrastructure.

From a health plan perspective, our initial actions included:

  • Relaxing our authorization around home-delivered meals. We loosened criteria to ensure that people who are sheltering in place or in quarantine, have the food they need, especially if their personal care attendants (PCAs) or homemakers or family members can’t get to them.
  • Ensuring coverage for any experimental or investigatory treatments associated with COVID-19.
  • Covering hygiene products, as we started getting tons of requests for items that are not typically covered like hand sanitizer, masks, and soap. While we don’t normally cover personal protective equipment (PPE) for PCAs, we are covering that now.

We also created a command center with a number of task forces to address priority areas, with each reporting up through the command center. These include, for example:

  1. Home Visits — Home visits are core to our care model. There isn’t enough PPE to do home visits at our usual rate and we do not want to expose employees or members to unnecessary risks. To alleviate this issue, we’re using FaceTime as much as we can, and have created field response teams in the east, central, and western parts of Massachusetts. These teams will do any in-home care that is deemed essential (such as insulin shots). We have been working extremely hard on making sure that they have appropriate PPE and developing processes and procedures for determining essential in-home services.
  2. Public Health — We started a public health team to keep up-to-date on where people can get tested for COVID-19, including where we can test in our own facilities, and to assist our public health partners with contact tracing. Countries that have successfully flattened the curve have been extremely rigorous about contact tracing and isolation precautions.
  3. Telehealth Workstream — With telehealth, we’re using what we and our members have available (phones, FaceTime, and Skype). We’re also developing workflows to help our nurses adapt to doing their work virtually. So much of our work is protocol driven and, accordingly, nurses and nurse practitioners are looking for protocols to guide their current efforts.
  4. Predictive Analytics — We are using predictive analytics to identify who is at high risk for COVID-19. Among our 36,000 members, our initial analyses suggest 20,000 are high-risk. We have also started to look at people who are high risk due to psychiatric factors.
  5. PPE Procurement — We have a procurement team that is looking at how to get whatever PPE we can, including nontraditional sources such as companies that have done construction work for us in the past.
  6. Behavioral Health — We are critically aware of the challenges of our members who have behavioral health needs. We have had a spike in emergency department and inpatient admissions due to behavioral health exacerbations. We’ve increased telehealth outreach for at risk members from our licensed behavioral health staff. Additionally, we are committed to keeping our Crisis Stabilization Unit (Psychiatric Step Down) at Marie’s Place in Brighton open during this time.

Q: What are your chief concerns right now?

A: What currently keeps me up at night are the people who are multi-handicapped or the elderly who are really dependent on personal care to be safe in their homes. At CCA we provide a lot of care and care coordination, but we’re particularly dependent on the people who change catheters and provide other critical in-home long-term services and supports to our members. What’s going to happen if a member’s PCA gets sick or needs to look after his or her kids who are now not in school or daycare? To expand the pool of PCAs serving our members, we’ve made more agency PCAs available to our members and are using home health aides as well, per recent state guidance. We’re lifting hourly restrictions, as has the state. We’re monitoring what facilities are closed and are working with the Aging Service Access Points and the Centers for Independent Living on member outreach. We are also thinking about how to meet critical needs, and how to figure out what’s a critical need versus a discretionary need.

Q: What are the most critical actions that states and the federal government can take to be good partners to you and your peers?

A: Notably, both the state and the federal government have done some really good things about lifting regulations around credentialing for this emergency situation. Ensuring equitable access to testing is a priority in Massachusetts and across the nation. We are working closely with our state partners around long-term services and supports — we’re thinking about what we are going to do if this situation worsens, and there’s somebody who’s handicapped who can’t get out of bed or change their catheter without help. Is there a way that preserves human dignity while leveraging one caregiver in more efficient ways? There have been conversations in Massachusetts about using the dorms of empty colleges and universities here, so people don’t feel like they are being warehoused or institutionalized. Together we’re thinking about who needs what and how to ensure that PCAs and home health aides are considered essential employees during statewide shelter-in-place advisories.

Ultimately, we will also need to address the financial impacts of all of this to our plan. For example, the current constraints on our operations are inevitably impacting our ability to accurately risk stratify our overall population, which will have major implications for how our Medicare and Medicaid rates are set in the future. Down the line there’s going to need to be some kind of financial reckoning, as a lot of Medicaid plans run on very narrow margins.

Q: How do you envision your current efforts changing “business as usual” once this crisis is behind us?

A: When this is all over, we’re going to have come up with so many great innovations that we were able to do because we had to. I don’t mean just CCA, but humanity. One example within CCA is that we are integrating care in entirely new ways through our newly deployed field teams. These teams are going to cover palliative care, transitional care, and ongoing care management. Our response to the virus is breaking down silos in a way that we might not have been able to do any other way, so that’s a plus for sure.

This blog post was originally published on the Center for Health Care Strategies blog.

Related Resource

Resource Center | Addressing Complex Care Needs Amid COVID-19