Approximately 9 million people in the United States are now dually eligible for health care benefits under both Medicare and Medicaid, according to the Centers for Medicare & Medicaid Services. But while dual eligibles are a small portion of the approximately 100 million people enrolled in the two programs, they account for a disproportionate amount of spending at $300 billion annually. This group also creates significant management challenges for organizations like AltaMed Health Services that strive to deliver the highest levels of care to its large safety net population while managing costs.

The nation's largest independent Federally Qualified Health Center with 43 clinics and an independent practice association, AltaMed serves more than 155,000 patients annually at sites throughout Southern California's Los Angeles and Orange counties. Certified as a patient-centered medical home by the National Committee for Quality Assurance, AltaMed has 140 providers and mid-level practitioners and 600 contracted specialists.

AltaMed has made care coordination a top priority; in fact, it is the basis for the accountable care network it helped to establish with regional hospitals. With its case management technologies and integrated care delivery strategies, AltaMed is successfully serving dual eligibles, a vulnerable and potentially costly population.

Responding to Unique Dual-Eligible Demands

To eliminate unnecessary services while expanding access to care for dual-eligible patients, AltaMed and other ACN participants invested in a technology strategy designed to improve utilization and case management process efficiencies, facilitate integrated care management processes at clinics or other facilities where they can have the greatest impact on patient care, and engage physicians by providing greater access to integrated health care information.

The organization uses its care management strategy for several care coordination activities, including automating discharge information such as clinical notes, care plans and patient discharge instructions generated by a hospital's electronic health record. Sharing the information with AltaMed facilities, clinicians now can conduct coordinated population health and disease management activities. Case and nurse managers throughout the ACN now have a tool that helps to guide interactions with patients to ensure they are following through with care plans and visiting the right physician or specialist. And with intelligent workflow capabilities, they can track all the activities involved with authorizations and referral management, reducing instances in which dual-eligible individuals receive duplicate services.

The ACN's care management solution is further enhanced by a connectivity platform that provides access to historical patient data including clinical notes, care plans and discharge instructions — data commonly generated in the hospital or other setting. This level of interoperability ensures that AltaMed providers are better equipped to manage care for dual eligibles in clinics and nursing homes rather than costly hospital beds and emergency rooms.

With an emphasis on care and utilization management and enabling technologies that help facilitate the care transitions process, AltaMed and the ACN have been able to improve access to services, reduce the number of emergency room visits, lower hospital stay lengths and trim the number of readmissions among its dual-eligible population. And with more advanced decision-support tools that fit within providers' workflow, the organization also has reported enhanced provider satisfaction and greater physician engagement.

Getting Other Programs off the Ground

The federal government is vested in promoting care coordination for dual-eligible patients. The Medicare/Medicaid Coordination Office and the CMS Innovation Center are providing $1 million to 15 states, encouraging them to devise strategies for implementing patient-centered models that fully coordinate primary, acute, behavioral and long-term services for dual-eligible Americans. States then will work with beneficiaries, their families and the health care community to develop demonstration proposals that can serve as models for the rest of the nation.

In one such instance, the California Department of Health Care Services is partnering with CMS to launch a three-year program this year that promotes coordinated care to senior citizens and those with disabilities who are dually eligible for Medi-Cal and Medicare. Programs like this are designed to help create the appropriate lines of communications and correctly align incentives so providers can have a material impact on the cost/quality equation.

While the industry is headed in the right direction in coordinating care for dual eligibles, it still must overcome formidable challenges related to deploying clinical and care utilization management in the settings where it can be most effective: at the point of care. Technology developers also must step up with interoperable solutions that promote widespread information-sharing, regardless of the technology or platform a provider chooses to use.

In spite of these challenges, such organizations as AltaMed are forging ahead with patient-centered health care in a collaborative environment for its expanding high-risk, dual-eligible population. As these providers expand their network reach within ACOs and other emerging delivery models, and as they develop partnerships with technology companies committed to offering user-friendly yet sophisticated systems, they will be in the best position to deliver the higher-quality, lower-cost services that will become the hallmark of health care.

Martin Serota, M.D., is vice president and chief medical officer of AltaMed Health Services in Los Angeles. Martha Santana-Chin is vice president of provider network operations and development for AltaMed.