Health Innovation Highlights: November 8, 2017

Full Edition


Keynote Delivered at SNP Alliance Annual Leadership Forum

Last week, Center Director Ann Hwang gave a keynote talk at the 13th annual Leadership Forum of the SNP Alliance in Washington, D.C. The SNP Alliance is a national leadership organization dedicated to improving total quality and cost performance through specialized managed care, and advancing integration of health care for individuals who are dually eligible for Medicare and Medicaid. The meeting included presentations on the future of SNP programs of all types, and focused on what the partisan debates in D.C. may mean for these programs after enjoying bipartisan support in the past.

Ann’s presentation, “Engaging Consumers: Addressing the Needs of Vulnerable and Complex Populations” featured the stories of older adult SNP members to draw out the vital importance of listening carefully to consumers in order to address the issues that are most important for their quality of life. Following Ann’s talk, there was interesting discussion among forum attendees related to social determinants of health (SDOH) and the need to better coordinate the roles of social service and medical providers. The Center and the SNP Alliance co-published a report this May that surveyed the ways in which SDOH impact Medicare-Medicaid beneficiaries and included case studies from SNP plans in Pennsylvania and Wisconsin.

Catalysts for Change: Advancing Equity in Health for the Dual Eligible Population

On Nov. 3, health care professionals from a wide range of organizations gathered in Detroit for a symposium on care models to address the needs of Medicare-Medicaid beneficiaries. Sponsored by the Henry Ford Health System, PACE Southeast Michigan and Community Catalyst, the symposium featured Center Senior Advisor Carol Regan who described the current policy and political environment in Washington, D.C. and the need for continued advocacy for consumers with complex health needs. Attendees then heard Dr. Gwendolyn Graddy, a Center Geriatrics Provider Advocate, and Bryan Dovichi, Medical Director and Senior Behavioral Health Program Leader at PACE Southeast Michigan, respectively; frame the need for addressing social determinants of health in their presentation on “An Integrated Care Practice Model for Managing the Dual Eligible Frail Population.” PACE Southeast Michigan is unique in that it embeds behavioral health in the program as a way to achieve seamless, coordinated care. A second panel addressed mental wellness and the multiple social and non-clinical services and supports that these consumers need in order to live in the community. Center partner, RoAnne Chaney, director of the Michigan Disability Rights Coalition, led the participants in an interactive workshop before the symposium concluded.

Center Hosts Roundtable at NASHP Annual Conference

On Oct. 25, Center Strategic Policy Manager Danielle Garrett joined Center partner Jesse Ellis O’Brian from the Oregon State Public Interest Research Group (OSPIRG) and Lynn Quincy from the Healthcare Value Hub in hosting a roundtable panel at the National Academy for State Health Policy (NASHP) annual conference in Portland, OR. NASHP’s annual conference is attended by more than 700 state health policy makers in the public, private, and nonprofit sectors from all 50 states and D.C. The roundtable focused on how to leverage the expertise and insights of consumer advocates in state policy work. State officials, policy experts, and advocates joined Danielle, Jesse, and Lynn in a productive discussion around strategies for engaging consumers and the benefits of including consumer voices in health policy work.



As November is National Family Caregivers Month (#NFCMonth), with  this year’s theme “Caregiving Around the Clock,” we are pleased to reprint an Eldercare Voices column on the importance of recognizing the vital role of family caregivers that first was published  in the February 2015 issue of The Dual Agenda (the previous name of this newsletter).

Moving Toward Person- and Family-Centered Care

Lynn Friss Feinberg, MSW

Person- and family-centered care (PFCC) generally refers to an orientation to the delivery of health care and supportive services that considers an older adult’s needs, goals, preferences, cultural traditions, family situation and values. It includes the person and, when appropriate, the family, at the center of the care team, along with health and social service professionals and direct care workers. This approach recognizes the role of family caregivers, who often are critical sources of support for older adults with chronic or disabling conditions. The demonstrations underway to integrate care for those eligible for both Medicare and Medicaid require participating health plans and provider groups to conduct a person-centered care plan that allows the enrollee to determine who can participate on his or her care team.

Person versus Patient

PFCC builds upon the concept of “person-centered care.” Traditionally, the term “person” is used in Long-Term Services and Supports (LTSS) settings, while the term “patient” is commonly used in a medical context. The term “person” rather than “patient” is preferred in that it connotes consideration of the “whole person,” including family relationships, when appropriate, and emphasizes continuity of care and support, and quality of life. In contrast, the conventional medical model is organized around providers, episodes of care, and specific diseases. Person-centeredness includes, but also looks beyond, the medical and physical health needs of the older adult.

The concept of person-centeredness and person-centered planning can be traced to changes that took place in the early 1970s as part of the independent living movement, led by people with disabilities. It is focused on the development of a social system in which all people with disabilities have the opportunity to lead productive, meaningful lives as integrated and valued members of their communities. The concept is equally applicable to older adults dealing with chronic and complex conditions.

Importance of the Family

We embrace the term “person- and family-centered care” because the term “person-centered care” alone may not adequately capture the importance of family in the lives of older people.

In 2009, family caregivers of adults with chronic or disabling conditions provided an estimated 40.3 billion hours of unpaid care at an estimated value of $450 billion. Without family caregivers, the health care and LTSS systems would be unable to meet the needs of older adults.

Family-centered care amplifies person-centered care by recognizing and supporting the vital role of family caregivers, building on the strengths of family connections. Some key facts:

  • The family is the main source of help for older people with functional limitations in daily life. Researchers estimate that 66 percent of older people with disabilities who receive LTSS at home get all their care exclusively from family members, mostly wives and adult daughters. Another 26 percent receive some combination of family care and paid help; only 9 percent receive paid help alone.
  • Frail older adults often rely on family to help them negotiate interactions with health and social service professionals. Family members and close friends often both provide and coordinate care. Such involvement can improve outcomes for older adults needing care and supportive services.
  • Family caregivers are often the main source for managing continuity of care. A consistent family caregiver will recognize his or her loved one as a whole person, not focusing exclusively on a specific disease, disorder, or episode of hospital care.
  • Family caregivers typically need information and support to function effectively in their caregiving role. Unless family caregivers are involved in assessment and care planning, they may not understand what is expected of them in their day-to-day caregiving role. Additionally, they may benefit from education, training, and access to other caregiver support services, such as respite care.
  • There is increasing recognition of the need for a family-centered approach in health care and LTSS to enhance mutually supportive relationships among clinicians, service providers, older adults, and their family caregivers.
  • Family caregivers of older people with complex chronic care needs may be vulnerable and at risk themselves. Reducing caregiver strain has been shown to prevent unnecessary hospitalizations, and prevent or delay the use of nursing homes.

The interests and decisions made by older adults and their family caregivers may not always be the same. Differences in the wishes, preferences, and capacity of older adults and family caregivers can present ethical challenges to health care and social service professionals. Conflicts may also arise among family members of an individual older adult. Providers can use skills in listening, empathy, conflict resolution, and mediation to help families cope and plan effectively. Holding a family meeting with a neutral facilitator or professional can mitigate disagreements, for example.

Key Elements of Person- and Family-Centered Care in Practice

The following are key elements of the PFCC model:

  • Respect and dignity for the older person and family. Health and social service professionals listen to and honor the person’s and family’s needs, values, preferences and goals for care – asking, “What is important to you?” They are aware of the individual’s and family’s cultural background and the language in which they choose to communicate, so that they can provide culturally and linguistically appropriate services.
  • Recognition of the whole person. In practical terms, a “whole person” orientation includes care and support that is integrated within and coordinated across the health care and LTSS systems, and acknowledges the individual in the context of relationships, especially with family and friends. It also emphasizes the person’s and the family’s well-being, taking into account physical and mental health, spiritual and cultural traditions, social supports, and the person’s engagement with her or his community.
  • Assessing and addressing both the individual’s and the family caregivers’ information, care and support needs and their experience of care. Based on an assessment of the older adult’s and family’s needs, a plan of care reflects the goals, values and preferences of the individual and family. Recognizing and listening to family needs and concerns are fundamental principles of good care planning, especially when the plan of care depends on a family caregiver, such as when an older adult has Alzheimer’s disease.
  • Promotion of communication, shared decision making and empowerment. This element is based on the principle that older adults, their families (if or when desired by the individual), and their health care and social service providers communicate together and build trust in ways that support individuals and families. Such decisions should respect individual and family goals and cultural needs, involve the person in everyday care choices, help the person and family better manage health and care options, and reduce caregiver strain.
  • Emphasis on coordination and collaboration across care settings. Good care for older people with complex chronic care needs and functional limitations requires a team of health and social service professionals, including direct care workers. This collaborative approach integrates family caregivers into the care team, engaging them as partners in care and providing tools for family caregivers, such as having one telephone number they can always call for help. Care and supportive services for older adults and their family caregivers are accessible, comprehensive, and continuous over time, and coordinated among providers and across care settings.


In recent years, PFCC has gained increased attention, but it is not yet commonplace in the delivery of health care and LTSS. To promote greater adoption of PFCC in everyday practice, public policies should support adherence to the key elements of PFCC; sufficient resources and supportive technology to address coordination and continuity of care; a trained interdisciplinary care team with the older adult and family at the center; and the provision of services and supports that matter most to older adults and to their families.

Lynn Friss Feinberg, MSW, is a senior strategic policy advisor with AARP’s Public Policy Institute. Her work focuses on family caregiving and long-term care issues. Prior to joining AARP in February 2011, Ms. Feinberg was the first director of the Campaign for Better Care, an initiative of the National Partnership for Women and Families. Previously, she held leadership positions at the San-Francisco based Family Caregiver Alliance, where she led the first 50-state study on publicly funded caregiving programs in the United States. Ms. Feinberg is a leading national expert on family caregiving and long-term care. She currently serves on the Institute of Medicine’s Committee on Family Caregiving for Older Adults, and is a past chair of the American Society on Aging.

Portions of this column reprinted with permission from the AARP Public Policy Institute. The original paper, with citations, is available here.



New ACAP Report Examines Housing Crunch for Older Adults with Low Incomes or Disabilities

The Association for Community Affiliated Plans (ACAP) this week released a new report, Bridging the Health and Housing Gap: Transitioning Medicaid Recipients from Institutions to the Community in the Context of Housing Shortages and Affordability that examines the issue of the lack of housing available for older adults with low incomes or disabilities.  

The report profiles the work of five ACAP-member plans to transition older adults who have low incomes or disabilities into the community and out of institutional settings. The five plans:

  • Health Plan of San Mateo (CA)
  • CareSource (OH)
  • Inland Empire Health Plan (CA)
  • LA Care Health Plan (CA)
  • Cardinal Innovations Healthcare (NC)

Implicit Bias in Care for Older Adults

A recent GeriPal podcast featured Dr. Kimberly Curseen, Associate Professor of Internal Medicine at Emory School of Medicine and Director of Outpatient Supportive/Palliative Care at Emory Healthcare, discussing how implicit bias influences providers in geriatrics, hospice and palliative care, as well as the role of that cultural competence and cultural humility should play in the way providers practice. Common implicit biases in geriatric and palliative care include: age, gender, race, ethnicity, financial, educational, personal background/religion and political views. In the podcast, Dr. Curseen offers examples of how providers’ implicit bias may cause them, for example, to speak to an adult child of an elderly patient rather than to the patient themselves. Or, a provider may assume patients of certain ethnicities with serious illness want “absolutely everything possible done.” To learn more about implicit bias, read Dr. Curseen’s interview at the Center for Advancing Palliative Care blog.

LTQA: Medicare Spends Three Times More on Older Adults with LTSS Needs

A Forbes article discusses a recent study on Medicare spending for older adults. The study, by researchers at the Long-Term Quality Alliance, found that Medicare spends an average of three times as much on the 13 percent of older adult beneficiaries with functional limitations requiring long-term services and supports (LTSS). Researchers found that this level of spending is not explained by these beneficiaries’ age, chronic conditions or Medicaid eligibility. Based on these findings, researchers recommend that innovations aimed at reducing Medicare spending focus on addressing and coordinating beneficiaries’ LTSS needs, regardless of whether the LTSS is financed by Medicaid, out-of-pocket savings or provided exclusively by unpaid family caregivers.

CMS Issues Final Results of Program to Reduce Avoidable Hospitalizations Among Nursing Home Residents

As reported in Modern Healthcare last week, CMS has released a final evaluation of its three-year Initiative to Reduce Avoidable Hospitalizations of Nursing Facility Residents. The initiative, which ran from 2012 to 2016, focused on long-stay nursing facility residents who are dually eligible and supported organizations that partner with these facilities to implement evidence-based interventions. Specifically, these organizations, known as enhanced care and coordination providers, hired nurses to provide education and clinical support to nursing home staff and help keep residents out of the hospital. The evaluation, conducted by RTI International, found a 17 percent drop in avoidable hospitalizations, which translated to nearly $50 million in savings.

The initiative now moves to the second phase, which pays nursing homes at Medicare rates to treat patients with one of six specific ailments—pneumonia, dehydration, congestive heart failure, urinary tract infections, skin ulcers and asthma—in their facilities rather than in the hospital. According to CMS, these six conditions are linked to approximately 80 percent of potentially avoidable hospitalizations among nursing facility residents.



Health Management Associates recently reported that the Colorado Department of Health Care Policy & Financing announced its intent to award contracts to five organizations to act as Regional Accountable Entities under Phase Two of the state’s Accountable Care Collaborative.


The Michigan Department of Health and Human Services (MDHHS) released the latest enrollment numbers for the MI Health Link program, the state’s duals demonstration.

Also, MDHHS released a report which presents the 2017 Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Health Plan Survey results of adult members enrolled in MI Health Link.

South Carolina

The South Carolina Department of Health and Human Services released a brochure explaining the role of the care coordinator in the Healthy Connections Prime program, the state’s dual eligible demonstration project. The purpose of the document is to provide members clarification on what a care coordinator is and what he or she may do for demonstration members.


Thursday, Nov. 16 (3-4 p.m. Eastern) – Webinar: Building Infrastructure to Advance Health Equity, presented by the National Collaborative for Health Equity, as the first in a four-part series. 

Please register for the webinar.

Tuesday, Nov. 21 (1-2 p.m. Eastern) – Webinar: Depression and Parkinson’s Disease - Treatment Options, presented by The Parkinson’s Foundation, in collaboration with The Lewin Group.

Please register for the webinar.

Thursday, Dec. 7 (12-1:30 p.m. Eastern) – Webinar: Interdisciplinary Care Teams for Older Adults, presented by The CMS Medicare-Medicaid Coordination Office, in collaboration with The Lewin Group and the Center for Consumer Engagement in Health Innovation.

Please register for the webinar.

Wednesday, Dec. 13 (2-3 p.m. Eastern) –  Webinar: A Disability Competence Resource: DCCAT, presented by The Lewin Group. The DCCAT is a free resource designed to assist health plans and health systems in evaluating their current ability to meet the needs of adults with functional limitations.

Please register for the webinar.