One CBO’s Successful Journey Through Managed Care Lights the Way Forward

Editor’s note: The John A. Hartford Foundation, the Administration for Community Living, The SCAN Foundation, the Gary and Mary West Foundation, the Buck Family Fund of the Marin Community Foundation and the Colorado Health Foundation have united to fund the Aging and Disability Business Institute, led by the Nation­al Association of Area Agencies on Aging. As a partner of the Aging and Disability Business Institute, ASA is collaborating with n4a on a series of articles and case studies in Aging Today that will pre­pare, educate and support community-based organizations and healthcare payers to provide quality care and services.
 
Sometimes when it is most needed, an organization, or the person at its helm, can serve as an inspiration or model for others to emulate. Connie Benton Wolfe, president and CEO of Aging & In-Home Services of Northeast Indiana, Inc., is that sort of leader in the evolving integrated care field.
 
As an Area Agency on Aging and an Aging and Disability Resource Center, Aging & In-Home Services (AIHS), the nonprofit social service organization in Fort Wayne, Ind., helmed by Benton Wolfe, has served older adults, people with disabilities and their family caregivers since 1974, but in 2010 ventured into the world of integrated and managed care. Through its eight-year journey, the nonprofit has navigated this space and continues to build strategic partnerships and innovative models of care.
 
From the vantage point of such hard-fought success, Benton Wolfe works to bolster other CBOs, to help instill in them a sense of pride for what they have accomplished and to challenge them to do more.
 
Focusing on the 5 Percent
Due to statistics familiar to professionals in aging (5 percent of the population uses more than 50 percent of healthcare resources, and those 5 percent of patients have complex medical and psycho­social needs) and the fact that CBOs have been working to address social determinants of health for decades (but remain under-resourced), Benton Wolfe argues that the national infrastructure exists to improve care and significantly reduce healthcare spending if we focus on that 5 percent of patients. She posits that the Aging and Disability Networks might be the best places to do that.
In these networks, clients’ health-related social determinants are regularly screened, interven­tions happen outside the health system from cross-sector providers, resources are diverse and in­formation and referral alone are not deemed sufficient.
 
“What if planners, legislators and payers all figured out that healthcare happens in costly insti­tutions but health happens at home, and that we have the capacity to impact health?” Benton Wolfe asked during her presentation at the 2018 Aging in America Conference.
“Handing the top 5 percent of patients who are the high utilizers of healthcare a resource list is not going to work, and establishing a care plan and telling people over the telephone is only a first step,” she said. “Successful outcomes require personalized engagement of that pa­tient. … [CBOs] have to work that care plan with the indi­vidual, and it takes specially trained professionals and paraprofessionals to engage that person, understand what’s important to them and then build and execute the plan,” she added.
 
Leveraging Technology, Making the Case
Benton Wolfe stresses the importance of technology to this process, and said CBO investment in technology is essen­tial and needs to be a high priority with both national- and state-level support. She cites the usefulness of the Return on Investment (ROI) simulator, a tool available through an AIHS partnership with Preferred Population Health Management (PPHM) and developed in con­junction with Indiana University Research & Technology Corporation under a Healthcare Innova­tion Award from the Centers for Medicare & Medicaid Services (CMS).
 
After negotiating for months to convince managed care entities that contracting with the Aging and Disability Networks to address social determinants of health was a good investment, she and partner Jim Vandagrifft, owner of PPHM, only began to see recognition of the value of engaging CBOs via use of the ROI simulator.
 
The simulator can predict and demonstrate to managed care executives and state Medicaid of­ficials the cost-savings associated with addressing social determinants of health in the community. It uses software to perform complex calculations not possible via spreadsheet. Tested on data from 4,500 patients over a period of 36 months, the calculator showed 99.5 percent accuracy against actual claims data from CMS.
 
AIHS brought the numbers into clear perspective for managed care executives by asking them to provide data on their top utilizer patients and then allow AIHS to apply the ROI simulator to that data. Benton Wolfe and Vandagrifft were able to show projected savings by layering statistics from AIHS’ Care Transitions and care coordination interventions over the hospital data. In one case, that meant that on a panel of 1,800 complex patients, the managed care entity would save $281 million over a five-year period.
 
Savings came in the form of reduced Emergency Department visits, reduced inpatient admis­sions, reduced inpatient length of stay and increased use of outpatient services. The ROI met the ratio of return needed to gain the attention of the managed care company and real movement on statewide and national contracts began.
 
Creating Successful Partnerships
How might the successes seen by AIHS be replicated by other CBOs? First, says Benton Wolfe, the medical community needs to begin to take CBOs seriously, by recognizing that what she now calls “social practitioners” are an evolving, specialty arm of medicine; that there are quantifiable advan­tages to non-medical interventions; and that the national and state infrastructure already exists for helping older adults in the community in the form of the Aging and Disability Networks.
 
On the CBO side, leaders need to figure out how managed care entities can pay CBOs. The 2018 Chronic Care legislation and CMS Regulatory Letter, as well as PACE expansion and the Altarum Institute’s Medicaring Community policy blueprint (tinyurl.com/yajnpj7c), are ways in which the atmosphere has recently changed to help CBOs.
 
The key to scaling medically and socially integrated care for patients with complex needs is in opening up billable codes for non-medical interventions specifically for complex patients. As Ben­ton Wolfe said, “Integrated care without integrated resources is just a nice concept.”
 
CBOs also must realize the need to change the way they do business: reorganizing to make con­tracting with healthcare entities easier, standardizing the services they provide in order to mea­sure outcomes and realizing that their successful future lies in offering services that are an exten­sion of healthcare.
CBOs also must be more comfortable with risk and make the investments needed to secure and manage data. Critical on the technology side is for CBOs to invest in and use health IT platforms that can communicate with electronic medical records and health information exchanges. Finally, there needs to be a renewed emphasis on quality and commitment by the Aging and Disability Net­works to achieve accreditation that is recognized by medical payers when needed.
 
A New Model for Moving Ahead
Benton Wolfe lauds the groundwork done by the U.S. Admini­stration for Community Living, the National Association of Area Agencies on Aging, the American Society on Aging and funding part­ners such as The John A. Hartford Foundation, The SCAN Foundation and the Gary and Mary West Foundation. She is the first to agree that “it takes a village to launch a movement” and learns every day from her progressive colleagues who are helping to break this new ground.
 
But for many CBOs, growing business quickly often is stymied by a lack of investment dollars and technology obstacles. Thus, AIHS and PPHM have re­­-cently launched a new model, Preferred Community Health Partners (PCHP), a management services organization (MSO) that secures managed care contracts at the national level and then leverages the strengths of statewide aging and disability networks as the infrastructure from which to deliver evidence-informed care coor­dination and care transitions for patients with complex needs.
 
This MSO provides a “plug-and-play” additional line of business for CBOs, with a full package of sup­ports needed to successfully execute contracts with managed care organizations. It is geared toward removing barriers for CBOs to participate as a health-related provider to complex patients through established managed care contracts.
 
There will be a technology platform built in to manage communications, referrals, delivery ser­vice protocols, billing, etc., as well as available training and technical assistance with developed standard operating protocols. Quality improvement will be continuous and outcomes will be mea­sured to prove the value of the community intervention.
 
PCHP has launched in two states, and plans to “go live” in three more in the next several months.
 
“CBOs are poised to play a critical role in not only improving health in this country, but also perhaps transforming healthcare by helping to control costs for its most complex and costly pa­tients,” says Benton Wolfe. 
 
The document was made possible by Grant Number 90PPBA0001 from the U.S. Ad­­ministration for Com­munity Living (ACL). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the ACL, or the U.S. Department of Health and Human Services.