Health Innovation Highlights: October 12, 2017

Full Edition


New Video on Culturally Competent Care for LGBTQ Older Adults

Released during LGBTQ History Month and in the spirit of National Coming Out Day (Oct. 11), this new video was jointly produced by the Center for Consumer Engagement in Health Innovation and SAGE, the nation’s largest and oldest organization serving lesbian, gay, bisexual and transgender elders. It illuminates the importance of person-centered, culturally competent care for LGBTQ older adults in all settings where they receive medical care and other health-related services. The four older adults featured in the video share, in poignant ways, how important it is for their providers to create an atmosphere of trust, open communication and mutual respect.

Delivering culturally competent care – whether it is related to a person’s race, ethnicity, cultural background, sexual orientation, language or literacy – is an important step toward furthering health equity. This is one of the Center’s core values which we strive to promote in all of our work. The Center is working to help promote concepts of person-centered care and help health systems and providers make progress in incorporating these best practices in their care delivery for all consumers.

Center Research Director Co-authors Article on How ACA Sabotage is Burdening Hospitals

In an article in STAT, Marc Cohen, Ph.D., Research Director at the Center and Director of the LeadingAge LTSS Center at the University of Massachusetts, Boston, along with Joel S. Weissman, Ph.D., and Amanda J. Reich, Ph.D., write about how ongoing Trump administration efforts to undermine the Affordable Care Act are likely to increase the amount of uncompensated care hospitals need to provide, imposing new financial burdens on these institutions. Strategies such as inadequate enforcement of the individual mandate, imposition of work requirements on Medicaid recipients, and failure to promote enrollment through advertising and outreach all can be predicted to lead to an increase in the amount of uncompensated care provided by America’s hospitals.

To maintain the progress in coverage the ACA has spurred, the authors recommend that the federal government:

  • Prompt states that have not expanded Medicaid to do so.
  • Enforce the individual mandate and employer participation rules.
  • Continue — and even increase — subsidies to insurers aimed at cost-sharing reductions.
  • Make necessary reforms to individual markets, such as a reinsurance program, to ensure they function well.
  • Offer a public insurance option in markets that carriers have been unwilling to service.
  • Avoid enacting legislation that will make insurance useless when it’s most needed.


Addressing the Social and Economic Determinants of Health: Evidence, Tools and the Path Forward

Three recent releases offer new evidence, tools and perspectives on the social and economic determinants of health. First, The Commonwealth Fund released findings of a study it supported examining how medical providers coordinate with local social services organizations. Researchers pointed to four primary attributes of “high-performing communities” where older adults’ health care use and costs are comparatively low: (1) regular collaboration and coordination between medical providers and social services organizations; (2) well-established partnerships on issues such as community planning, housing, cross-agency coordination and post-hospitalization case management; (3) strong norms encouraging collaborative problem-solving, along with influential local political organizations and financially stable hospitals; (4) older adults have high levels of both financial support and support from families and religious organizations.

Second, The Health Care Transformation Task Force has released the recording and materials from its recent webinar, Financing Integrated Social Services for the High-Need, High-Cost Patient Population. In addition to presenting a framework for social service integration and financing, the webinar featured speakers from ConcertoHealth and agilon health.

Finally, in a new post on the JAMA Forum, Brookings Institution senior fellow Stuart Butler argues that we have a long way to go to move our health care system to a place that properly reflects social determinants. Butler goes on to name several fundamental steps needed to bring about this change. Specifically, we need to build the evidence base for the linkages between health and other social conditions. Relatedly, we need to improve our data collection systems in order to measure the return on investment of addressing social determinants. Finally, Butler points to the need for flexibility, in terms of payment models, budgets and agency coordination.

New Resource: The Intersection of Disability, Race and Poverty

A new report from The National Disability Institute (NDI), examines a host of issues on the intersection of disability, race and poverty in the United States. Among the report’s findings are that African Americans are more likely to have a disability than any other demographic group and that nearly 40 percent of African Americans with disabilities live in poverty, as compared with only 24 percent of non-Hispanic Whites.

The report’s authors then examine several factors that affect the relationship between race, poverty and disability:

  • Poverty causes disability: For example, children living in poverty are more likely to have asthma and other chronic illnesses.
  • People in poverty are less able to treat disabling conditions and to mitigate their impact: For example, because of limited access to high-quality medical care, a condition may go untreated.
  • Disability causes poverty: For example, disability can severely limit a person’s employment opportunities and earnings.
  • Race is linked to poverty and disability: For example, African Americans as a group continue to have lower incomes and poorer health status than whites.

The Value of Chronic Disease Self-Management Programs

A new issue brief from the Administration for Community Living (ACL) discusses self-management programs for adults with chronic conditions. The brief devotes great attention to Stanford University’s Chronic Disease Self-Management Program (CDSMP), which relies on peer leaders who educate small groups about chronic disease self-management. It also presents the research and findings on CDSMP which include improvements in self-reported health, pain, fatigue, depression, communication with physician and medication compliance. These positive health outcomes also resulted in reductions in emergency room visits and hospitalizations, which translated to significant cost-savings. Finally, the ACL authors rely on the agency’s experience in developing a network that reached more than 30,000 CDSMP participants to describe options for states and localities related to implementing and sustaining these programs.

10 Ways to Strengthen Integrated Care

Drawing from three years of Cal MediConnect evaluation results, a new brief from The SCAN Foundation highlights 10 recommendations for federal policymakers to share with states to improve integrated systems of care for people with Medicare and Medicaid. Among the recommendations are that CMS should:

  • provide clear guidance to states on the scope and minimum requirements of person-centered care
  • increase incentives for health plans to help transition long-stay nursing home residents to community-based settings
  • develop a framework for states and health plans to develop systems that integrate behavioral health services for a seamless care experience for individuals.


Whatever It Takes: Building a Healthcare System like "Cheers"

(Where Everyone Knows Your Name)

Steven M. Stein, MD

Fragmented care delivered by fragmented providers with fragmented documentation during fragmented hours in fragmented settings through fragmented funding has not provided person-centered care. “Whatever It Takes” is an attempt we are undertaking in Michigan to change that narrative in an incremental way for that person or family member who is concerned that they are experiencing an emergency.

The “Whatever It Takes” program brings together Trinity Health At Home, St. Joseph Mercy Hospital – Ann Arbor (SJMH-AA), Integrated Health Associates (IHA) and Huron Valley Physician Association (HVPA) physician groups, Emergency Physicians Medical Group, Huron Valley Ambulance (HVA), and some key community agencies such as the Area Agency on Aging 1B to consistently assess situations considered by a patient (or a family member or formal caregiver) receiving skilled home care services to be urgent and then deliver an immediate response in the manner that is the most appropriate and cost-effective for each situation. “Whatever It Takes” accepts the fact that patients and families often reach out in different ways when they have concerns. They may call their physician's office. They may call their home care agency. Those with a personal care response system may press their pendant button. The home care agency might identify an urgent situation through remote monitoring (e.g., major gain in weight in someone with a history of heart failure who also documents that they are feeling more short of breath).  The person or family member may call 911. 

The program rests on four major pillars:

The first pillar is establishing a minimum common data set (MCDS) that gives providers immediate access to some key information that is always on hand when a patient believes he or she is experiencing a medical emergency and calls for help. The provider will know certain elements of that person's history: contact information for the patient’s physician, physician practice case manager, and “in case of emergency" person; chronic conditions, allergies, history of recent hospitalizations; some key social determinants of health (e.g., transportation issues, living alone, history of elder abuse, etc.); Durable Power of Attorney for health care/advance care plan/DNR status; and any risk stratification categorization (i.e., high, medium, low risk) that has been previously done on the patient. We call the MCDS the "Cheers" Form – as it is one incremental step toward building a health care system like Cheers – where everyone knows your name.

The second pillar is that when there is an initial reach out by the patient, the home care or physician office triage nurse assesses the situation by utilizing physician-approved telephone triage protocols. If the situation is not an emergency that requires an immediate in-person assessment, the patient is reassured and coached on an approach to symptomatic relief. A follow-up visit with their doctor is arranged, if needed. In a true emergent or urgent situation, the triage nurse dispatches a community paramedic or home care nurse who immediately drives to the home and assesses the patient; the patient and paramedic or nurse video-conferences with the physician (either the primary care physician or covering provider or an emergency room physician), obtains orders for stat diagnostics (e.g., labs, oximetry, EKG, etc.) that are done right there in the home and then treats the patient under the telehealth supervision of the physician. If the treatment (e.g., IV dose of Lasix for heart failure, nebulizer treatment for asthma, first dose of IV antibiotics for a pneumonia, etc.) is effective and thus does not require an immediate transfer to the ER, a follow-up appointment with the relevant physician will be arranged for the same day or next day by the home care agency. Other times, the in-home treatment may be unsuccessful and the physician will make the decision to have the community paramedic bring the patient to the physician's office, an urgent care center or, when required, to the ER. Of course, if the situation requires a transfer to the ER right away, the transport would occur in the usual way via an advanced life support ambulance.

The third pillar will ensure that each clinical incident is well-documented and that the information related to both the assessment and treatment of the patient is sent to the primary care physician immediately. The primary care physician is thus able to use this information for assessment of the patient during the next office visit, which may very well be the same day. For example, the documentation of an event that happened at 2 a.m. will be in the hands of the physician should the patient come into their office for a same day appointment at 11 a.m.

The fourth pillar is "see something, do something."  If we identify any other needs (e.g., a need for meals on wheels, a more thorough home safety evaluation or a follow up mental health visit, etc.), the home care agency or area agency on aging will ensure that the patient is connected to the relevant community resource and that those needs are subsequently addressed by that agency.

Initially, the program serves only Medicare FFS home care patients who are enrolled in St. Joseph Mercy Home Care and Hospice in Washtenaw County (Ann Arbor/Ypsilanti/Chelsea). The two-year goal is to serve all patients in the Medicare Shared Savings Program and CPC+ practices affiliated with SJMH-AA. That will take us from serving many hundreds of patients to serving many thousands of patients. The majority of the funding received from Trinity Health, the Michigan Health Endowment Fund and Huron Valley Ambulance will be used to pay for care that is presently uncompensated (e.g., paramedic services that do not result in a transfer of the patient to the ER, physician telehealth services, fixing a broken ramp, etc.) 

Going forward, it is our expectation that beneficial outcomes in this approach will drive different payers to request entry for their members. This would not only include traditional payers such as health plans, ACOs, Bundled Payments for Care Improvements (BPCI) Model 2 hospitals, government payers (such as Medicaid and the VA) but also monthly or yearly subscription fees from retirement communities, nursing homes and even individuals. We even expect that progressive physician offices may choose to have the “Whatever It Takes” team serve as an after-hours answering service as value-based purchasing requires a different kind of response than "If you believe that you have an emergency, go to the ER or call 911."

Yes, the “Whatever It Takes” group of providers is committed to doing Whatever It Takes and building a health care system like "Cheers" – where everyone knows your name.

Dr. Steven M. Stein is the Chief Medical Officer for Trinity Health Continuing Care. He has oversight for Trinity Health's home care agencies, hospices, nursing homes, PACE organizations and senior housing complexes. Dr. Stein received his Bachelors in Computer Science at Columbia, his medical degree at Cornell and did his residency at Montefiore Medical Center. He did his geriatrics fellowship at Harvard where he also received a Masters in Health Services Administration at the School of Public Health and subsequently served on the faculty of the Medical School as a member of the Division on Aging. His career has placed him in leadership positions in both managed care and on the provider side – consistently advocating for our most vulnerable citizens receiving high quality, cost-effective health care that is targeted to what matters most to the specific individual served. 



The Medicare-Medicaid Coordination Office posted an updated three-way contract for the California dual eligible demonstration project, Cal Mediconnect. The new contract is updated in several areas, key ones being that it conforms to elements of the new Medicaid managed care rules and this year’s California budget. In related news, drawing from three years of Cal MediConnect evaluation results, a new brief from the SCAN Foundation highlights 10 recommendations for federal policymakers to improve integrated systems of care for people with Medicare and Medicaid.


The state of Hawaii submitted an 1115 Medicaid waiver requesting reimbursement for supportive housing services for individuals who are chronically homeless and have a behavioral, physical or substance use disorder diagnosis. The funds would be used to appoint state employees to help eligible beneficiaries find housing and provide moving assistance. The waiver is currently under review by the Centers for Medicare and Medicaid Services and is open to public comment through Oct. 17.

South Carolina

The state of South Carolina released the October 2017 stakeholder update for its dual eligible demonstration project, Healthy Connections Prime. The full update is available here.


Sunday, Oct. 1 – Early Bird Registration Deadline for Putting Care at the Center 2017, the second annual conference presented by The National Center for Complex Health and Social Needs. The conference will be held Nov. 15-17 in Los Angeles, with pre-conference workshops taking place Nov. 13-15. This year’s conference is co-hosted by Kaiser Permanente. 

Monday, Oct. 16 (12-2 p.m. Eastern) Webinar: State of the Science: Long-Term Services and Supports and Caregiving for Adults Aging with Disability (Session 1), presented by The Lewin Group with support from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the National Council on Aging (NCOA).

Please register for the webinar. 

Tuesday, Oct. 17 (3-4 p.m. Eastern) Webinar:Transformation to Value: A Provider Perspective, presented by the Health Care Transformation Task Force. 

Please register for the webinar.

Wednesday, Oct. 18 (12-2 p.m. Eastern) Webinar: State of the Science: Autonomy and Access for Adults Aging with Disability (Session 2), presented by The Lewin Group with support from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the National Council on Aging (NCOA).

 Please register for the webinar. 

Friday, Oct. 20 (12-2 p.m. Eastern) Webinar: State of the Science: Health Care Policy, and Implications for Adults Aging with Long-Term Disability (Session 3), presented by The Lewin Group with support from the National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR) and the National Council on Aging (NCOA).

 Please register for the webinar.

Thursday, Nov. 2 (3:30-5 p.m. Eastern) Webinar:Preventive Care and Health Screenings for Persons with Disabilities, presented by the CMS Medicare-Medicaid Coordination Office (MMCO), in collaboration with The Lewin Group. 

Please register for the webinar.

Thursday, Nov. 2 (4-5 p.m. Eastern) Webinar:Transformation to Value: A Payer Perspective presented by the Health Care Transformation Task Force.

Please register for the webinar.

Wednesday, Nov. 8 (1-2 p.m. Eastern) Webinar:Support for the Working Family Caregiver presented by the American Society on Aging, in collaboration with The Lewin Group. 

Please register for the webinar.