Health Innovation Highlights: February 8, 2018

Full Edition


Center Launches “Care That Works” Series with a Brief on the PACE Program

Innovations in how to best care for people with complex health and social needs are happening across the country. Our new “Care That Works” series seeks to examine and elevate these successful programs and share the stories of the people they serve.

The first brief in this series, “Care That Works: PACE,” shares an overview of the ground-breaking Program of All-Inclusive Care for the Elderly (PACE) pioneered in San Francisco in the early 1970s, and the story of a current PACE participant in Michigan, Mr. Clarence Semmes. The goal of PACE is to help older adults live in the community as independently as possible for as long as possible. To do that, these programs offer a wide range of services, from adult day programs to medical, nursing, social services, transportation, pharmacy and long-term services and supports. Care is provided at PACE centers, at home or in the community via contracts with other providers.

Center Staff and Partners Featured at Event on Individuals with Complex Care Needs

On Wednesday, Jan. 31, the Bipartisan Policy Center (BPC) held an event in Washington, D.C. to unveil its new publication, A Policy Roadmap for Individuals with Complex Care Needs. The first panel, which included Community Catalyst Strategic Advisor Cindy Mann, discussed the ways in which the health care system fails people with complex conditions and strategies for changing the system to better meet those needs. In a second panel, Center Research Director Marc Cohen and Senior Leader Judy Feder discussed their proposal to address long-term care insurance contained in a new report, A New Public-Private Partnership: Catastrophic Public and Front-End Private LTC Insurance. This innovative proposal focuses on assisting middle-income people through a publicly financed catastrophic insurance program along with gap-filling private long-term services and supports insurance to promote comprehensive insurance protection. A video recording of the BPC event can be viewed in its entirety here.

Evaluation Report Published on Maryland Faith Health Network Pilot

In February 2016, Center partner the Maryland Citizens’ Health Initiative (MCHI), in collaboration with LifeBridge Health System, launched a pilot program with the goal of developing a standardized, proven approach for reducing hospital readmissions through partnerships between the faith community, hospitals and community-based organizations. Through the program, known as the Maryland Faith Health Network, LifeBridge partnered with faith communities to provide spiritual and domestic support to congregants who had been admitted to one of the system’s three hospitals. An evaluation of the pilot program, which ended in October 2017, has now been released. The evaluation found the pilot was successful in establishing an infrastructure to implement and evaluate the impact of scalable population health programs involving partnerships between health care institutions, community-based organizations and faith communities. Some findings:

  • Seventy congregations representing eleven denominations in Baltimore City, Baltimore County, and Carroll County participated in the pilot.
  • More than 170 congregation leaders and volunteers were trained to support fellow congregation members following hospitalization.
  • 1,818 congregation members enrolled in the Network.
  • When compared to individuals not enrolled in the Network, congregation members who had been treated at the three hospitals had 75 percent lower inpatient utilization after one month in the Network and 17 percent lower utilization after one year in the Network.


Recommendations Released for Addressing Social Determinants of Health Through Community Health Workers

The Hispanic Health Council has released a comprehensive policy brief making recommendations for addressing social determinants of health through increasing emphasis on training and support for community health workers. The brief draws on the varied and significant roles community health workers play in improving outcomes and making sustainable changes to patients’ home and environment. The goal of the brief is to offer recommendations for transforming health systems in ways that fully integrate the needs of community health workers at the core of the model so that patients can be better served.

Recommendations for creating a community health worker-focused system are bundled into the following categories:

  • Payment
  • Caseloads
  • Recruitment
  • Training
  • Trauma-Informed Mentoring and Supervision
  • Integration of Community Health Workers in Care Teams; and
  • Documenting the Effects of Community Health Worker Services on Social Determinants of Health

New Law Aimed at Supporting Family Caregivers Signed

AARP reports that a new bill aimed at supporting family caregivers has been signed into law.

The law, known as the RAISE Family Caregivers Act, requires the federal government to create an advisory council within the next 18 months to deliver strategy and policy recommendations for better supporting family caregivers. About a third of family caregivers are working at least 20 hours per week assisting a loved one, and this advisory council is expected to provide a roadmap for better integrating their needs into the health system.

State Innovation is Critical to Improving Health

The National Academy for State Health Policy (NASHP) has released a brief describing the findings from their October 2017 convening of state health policy officials focused on improving population health through accountable care. The brief provides an analysis of 12 state accountable care structures and offers specific steps states are taking to ensure the success and sustainability of accountable care models for their residents. In particular, NASHP researchers use the brief to:

  • identify policy levers to support health system transformation through accountable care frameworks
  • outline return on investment measures and accountable care evaluation models, and
  • describe the resources states are using to invest in and sustain improvements in health through accountable care.

The brief includes a detailed narrative as well as a comparative chart of each state’s leaders and strategies. A quick-guide to the findings is also available on the NASHP website.



The Alabama Medicaid Agency will release a request for proposal (RFP) for its Medicaid long-term services and supports program, Integrated Care Network (ICN), in March 2018. The state will select a single ICN entity that will work with individuals in nursing facilities and in home and community-based (HCB) settings to improve education and outreach, promote HCB services, and expand comprehensive and integrated case management. Alabama will announce the award winner in Spring 2018 and the program will go live in October 2018.


UCSF Institute for Health and Aging and UC Berkeley Health Research for Action released a research brief examining providers’ experience with Cal MediConnect (CMC), the state’s dual eligible demonstration project. For the most part, providers found the program’s benefits an added value for their patients, but identified challenges and areas of opportunity to improve the program. Some of the key findings:

  • Providers perceived CMC to be part of a positive trend toward more integrated systems of care and wished to see the program sustained and improved.
  • CMC’s additional benefits added value, particularly the care coordination, transportation, durable medical equipment, vision and pharmacy benefits, though awareness of them could be improved and access more consistent.
  • Providers unaccustomed to serving dual eligible members, such as federally qualified health centers (FQHCs), reported being unprepared for the complexity of medical care required by many duals, presenting challenges with time and resource management.
  • Many providers experienced challenges navigating member eligibility data, as well as CMC referral and authorization processes.
  • Providers struggled with managing their patients’ care transitions when they were not able to work CMC plans.

New York

The new CEO of the New York City Health + Hospitals system has moved quickly to implement new delivery reform initiatives. H + H has announced plans to adopt a system-wide care management program designed to improve care for high-need patients, regardless of health insurance or immigration status. The program will use a variety of different kinds of care coordinators help patients navigate the health system and also to address needs – like food and housing – related to the social determinants of health. Make the Road New York, Center partner, has been working for the past year with H+H to improve the system’s work with community-based organizations that address the social determinants, and to widen access to quality health care services for immigrants. 


The Oregon Health & Science University, Center for Health Systems Effectiveness has prepared an evaluation report for the Oregon Health Authority on the state’s Medicaid demonstration waiver, which allowed the state to test new approaches to health care delivery and payment through coordinated care organizations (CCOs). Some of the evaluation report’s key findings:

  • CCOs were associated with reductions in spending growth and improvement in some quality domains.
  • Experience-of-care measures and self-reported health status for CCO members also improved.
  • Measures of access to care decreased slightly among CCO members, likely due to Oregon's 2014 Medicaid expansion: total enrollment in physical health care coverage increased by over 385,000 members from December 2013 to December 2014 and use of services by new Medicaid members may have reduced the ability of previously enrolled CCO members to get appointments and services.


Friday, Feb. 16 (2:30-3:30 p.m. Eastern) Webinar: A Conversation with Dr. Atul Gawande, presented by Grantmakers In Aging, and made possible through the sponsorship of The John A. Hartford Foundation.

Please register for the webinar.

New Disability-Competent Care Webinar Series for 2018

The CMS Medicare-Medicaid Coordination Office (MMCO), in collaboration with The Lewin Group, is presenting a seven-part Disability-Competent Care Webinar Series in 2018. This series is intended for interested providers and health care professionals, front-line staff with health plans and provider practices, and other stakeholders. It will introduce and explore the many uses of the Disability-Competent Care (DCC) model. The first two webinars are:

Wednesday, Feb. 21 (2-3  p.m. Eastern) Improving Accessibility of Provider Settings This webinar will focus on medical office accessibility, including physical and communication barriers that may impede participants with disabilities from receiving care.

Please register for the webinar.

Wednesday, Feb. 28 (2-3  p.m. Eastern) Serving Adults With Disabilities On the Autism Spectrum. This webinar will provide a basic understanding of the autism spectrum and will examine the unique care management needs of adults with disabilities who are on the autism spectrum. The discussion will highlight the experience of being autistic and the disparities and barriers these participants experience in obtaining care.

Please register for the webinar.

Monday, April 16 Deadline for submission of applications for 2018-2019 Health and Aging Policy Fellows program, to begin October 2018. The program aims to create a cadre of leaders who will serve as change agents in health and aging policy to ultimately improve the health care of older adults. Full program and application information here.