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

December 2019

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, explored 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 described their care transition approaches, including how they identified individuals in need of supports, worked with delivery system and community-based partners, and addressed the needs of members with housing insecurity. Speakers shared program outcomes as well as lessons for health care stakeholders interested in improving care transitions for high-need populations.


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 welcomed 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 described key elements and results from iCare’s Follow to Home program, which is designed to improve care transitions and reduce readmissions. She also discussed how the plan adapted the program to meet the post-hospital discharge needs of members who are homeless.

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 provided 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 provided 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

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