Improving Care for California's Older Adults:
The Role of Community Health Centers and
Public Hospital Systems

AUTHORS
Bobbie Wunsch, Rafael Gomez, Laura Hogan, and Marty Lynch
About the Authors

This report was prepared by Bobbie
Wunsch, MBA, founder and _ partner;
and Rafael Gomez, MPP; Laura Hogan,
MPA; and Marty Lynch, MPA, PhD, senior
health care consultants, with Pacific
Health Consulting Group. Pacific Health
Consulting Group provides management
consulting services to public sector and
community-based health care  organi-
zations. With a focus on managed care
development and health care delivery ser-
vice improvement in the California safety
net, Pacific Health Consulting Group's cli-
ents include community health centers,
state and local health agencies, public hos-
pitals, local public Medi-Cal managed care
plans, and other organizations that deliver
or finance health care services.

About the Foundation

The California Health Care Foundation
is dedicated to advancing meaningful,
measurable improvements in the way the
health care delivery system provides care to
the people of California, particularly those
with low incomes and those whose needs
are not well served by the status quo. We
work to ensure that people have access to
the care they need, when they need it, at a
price they can afford.

CHCF informs policymakers and industry
leaders, invests in ideas and innovations,
and connects with changemakers to create
a more responsive, patient-centered health
care system.

DESIGN BY DANA KAY DESIGN

Contents

3
4

10
13
18
19
20

Introduction

The Changing Demographic and Safety-Net
Landscape

Safety-Net Response to the Changing
Landscape

Older Adult Population Needs and Service
Models

Emerging Practices and Percolating Innovation
Clinical and Business Model Considerations
Looking Forward

Conclusion

Endnotes
Introduction

California's demographics are changing, with the
proportion of the state's population age 50 or older
increasing at a record pace. Older adults also repre-
sent the fastest-growing age cohort receiving care
through California's safety-net provider system. As
the state's population shifts, so do the care needs
for the older adult population, particularly those
with low incomes, many of whom are eligible for
both Medicare and Medi-Cal (dually eligible enroll-
ees). Dually eligible enrollees are more likely to
experience multiple health and social needs com-
pared to the general Medicare population; this
complexity calls for tailored and highly coordinated
services inside and beyond clinical settings.

While California's community health centers and
public hospitals have long provided integrated care
to adults, children, and families with low incomes,
historically these care settings have not empha-
sized services specifically focused on older people
with low incomes and complex medical conditions.
Despite this gap, the community health centers and
public hospitals that compose California's safety net
are well positioned to provide coordinated, inte-
grated care to this growing group of Californians,
given these organizations' unique skill set and cul-
ture supporting comprehensive care for complex
populations.

This report outlines potential strategies and oppor-
tunities to meet the emerging care needs of older
Californians with low incomes, describes a range of
policy initiatives launching in California that present
new opportunities for improved care for this popu-
lation, highlights findings from a literature review
of practices and programs designed to improve
access and quality for older adults, and summarizes
perspectives and insights from interviews with com-
munity health center and public hospital system
leaders around emerging approaches and chal-
lenges they face in serving older adults with low
incomes.

Key Terms

This report includes information about multiple
types of safety-net providers. Safety-net providers
is an overarching term referring to public and
nonprofit health care organizations that focus

on low-income and vulnerable populations. The
report refers to specific types of safety-net provid-
ers where relevant. Community health centers
refers to Federally Qualified Health Centers
(FQHCs) and FOHC Look-Alikes. Community
health centers and FOHCs may be county-
affiliated entities or community-based nonprofit
entities. Public hospital systems include county-
affiliated hospitals, FOHCs, and non-FQHC health
centers and other programs or services.

While the term older adults is often used to refer
to people age 65 or older, this report takes a
broader view, focusing on adults age 50 or older,
given the higher rates of chronic conditions at
younger ages for people with low incomes served
by safety-net providers. However, much of the
data reported are specific to older adults age

60 or older, or 65 or older, and people enrolled

in both Medicare and Medi-Cal (dually eligible
enrollees). Information on adults age 45 to 64

is included in consideration of the changing
needs of adults as they age. Adults of all ages
experiencing homelessness, multiple chronic
conditions, or functional impairments benefit from
a similar set of services to people in the older
adult population age 65 or older.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems
The Changing
Demographic and Safety-
Net Landscape

In 2020, there were 6.2 million adults age 65 or
older in California representing about 15% of the
state's population; this group is projected to total
8.4 million, almost 20% of Californians, by 2030."
The increasing senior population is driven largely
by baby boomers, who began to reach age 65 in
2011. The largest growth of seniors over the next
two decades will occur among those age 85 or old-
er." This age cohort is projected to grow to almost
two million by 2040.3 Currently, the majority of
older adults in California are White; however, older
Californians will rapidly become more ethnically and
racially diverse, resulting in an older adult popula-
tion that will be majority people of color by 2035.*

As part of this trend, the state's population age 60
or older will be nearly one-third (29%) Latino/x and
16% Asian by 2030.°

California safety-net providers are increasingly
caring for an aging and more complex patient
population. Utilization data for both community and
county FQHCs indicate that growth in the number of
patients age 65 or older is already occurring.® (See
Figure 1.) While older adults still represent a smaller
percentage of overall patients served compared
to younger age groups, the rate of growth among
older adult patients has outpaced these other age
groups in recent years.' Between 2014 and 2019,
the percentage of community FQHC patients age
65 or older increased from 6.3% to 8.5% of the total
patient population, an increase of 80%, compared
to a 32% increase among total patients during that
period.' The increase among patients age 65 or

Figure 1. Percentage Increase in the California FQHC Patient Population, by Age, Community vs. County, 2014-19

 

™ 45-64 65+ Mi ALLAGES

 

     

 

 

Community FQHC County FOHC
45-64 65+ ALL AGES 45-64 65+ ALL AGES
2014 875,578 223,683 3,572,345 35,876 8,399 116,395
2019 1,119,386 402,060 4,732,648 62,018 22,468 245,875

 

Source: Author analysis of California FQHC data from the 2014 and 2019 "Health Center Program Uniform Data System (UDS) Data Overview," US Health

Resources and Services Administration (HRSA).

 

California Health Care Foundation

www.chcf.org 4
older was the highest among all adult age groups
(including age 19 to 44 and age 45 to 64) and also
higher than youth (age 18 or younger). While the
proportion of patients age 45 to 64 has remained
steady since 2014, community FOHCs in California
now serve more than 1.1 million patients in this age
group - almost one in four patients."

The proportion of county FOHC patients age 65
or older also grew as a proportion of total patients
over the five-year review period. In 2014, 7% of
patients at county FOHCs were age 65 or older,
and this increased to over 9% in 2019."° (See
Figure 1.) Additionally, in California's public hos-
pitals, inpatient discharges for patients age 60 or
older increased from 21% to 28% between 2014
and 2019. Inpatient discharges with Medicare as
the payer also increased from 11% to 18% during
the same period."' As with FQHCs, the significant
growth in the percentages of older adults receiv-
ing care in public hospitals is noteworthy and likely

reflects longer-term trends driven by demograph-
ics; however, the overall number of older adult
patients remains relatively small.'

Patients eligible for both Medicare and Medi-Cal
(dually eligible enrollees) represent the major-
ity of FOHC Medicare patients. Nationally, the
percentage of dually eligible enrollees served by
FQHCs nearly doubled between 2002 to 2017,
from 9.2% to 17.9%.'* In California, dually eligible
enrollees total 1.58 million statewide." Nearly 6 in
10 (57%) FQHC Medicare patients receiving care
in 2019 were dually eligible enrollees. In 2019,
county FQHCs had a higher proportion of Medicare
patients than community FQHCs (14% compared
to 10%) and a higher proportion of dually eligible
patients (9% vs. 6%), suggesting greater complexity
within the county FQHC adult patient population.
(See Figure 2.) Although FOHCs served only 16% of
all dually eligible Californians in 2019, this rate var-
ied dramatically by community; in 14 rural counties,

Figure 2. Proportion of California FQHC Patients Age 18+ with Medicaid and/or Medicare, Community vs. County,

2014 and 2019

 

 

9% | 10%
|

Dually Eligible

Medicaid Only

Medicare Only
Community FQHC

* Data on dually eligible enrollees not available in 2014.

 

WM 2014 @ 2019

 

ey
ae

Medicare Only
County FQHC

3
*

Dually Eligible

Medicaid Only

Source: Author analysis of California FQHC data from the 2014 and 2019 "Health Center Program Uniform Data System (UDS) Data Overview," US HRSA.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 5
community FOHCs provided care to 40% or more
of the dually eligible population in each county.

Safety-net providers are well positioned to care
for the multiple needs of dually eligible enrollees.
Dually eligible enrollees are nearly twice as likely to
have three or more chronic conditions compared
with Medicare-only enrollees. Diabetes, kidney dis-
ease, and heart disease are all significantly more
prevalent among dually eligible enrollees, as are
functional limitations and disabilities such as intel-
lectual disability and mobility impairment.'® FQHCs
also serve higher proportions of dually eligible
patients with mental health conditions, substance
use disorders, and disabilities than private provid-
ers." Although more likely to serve patients with
complex needs, California FOHCs meet or exceed
overall HEDIS (Healthcare Effectiveness Data and
Information Set) performance measures for hyper-
tension and diabetes control, two measures relevant
for older adults.'®

Bringing the strengths of safety-net providers more
intentionally to the care of older adults may con-
tribute to better health outcomes. Safety-net health
care providers, including community health centers
and public hospital systems, offer culturally adapted
care; integrated physical, oral, and behavioral
health services; and a history of support services to
address social needs. These attributes may position
these settings as high-quality providers for older
adults based on their existing strengths. One area
of potential opportunity is for community health
centers and public hospital systems to serve as pro-
viders for Medicare Advantage (MA) health plans,
including those specifically aimed at serving dually
eligible enrollees (Dual Eligible Special Needs
Plans, or D-SNPs). Currently, research shows a high
prevalence of social needs among enrollees of MA
plans but shows varied and often lower Medicare
Star Ratings among MA plans serving dually eligi-
ble populations, and suggests that MA plans with
better quality ratings include practices that address

both clinical and social needs and offer tailored ser-
vices and supports.'? Because community health
centers and public hospital systems already provide
many of the kinds of integrated clinical and social
care that can improve the quality and quality ratings
of MA plans, they have the potential to fill an impor-
tant provider role for MA plans (including D-SNPs)
in the future.

Safety-Net Response to
the Changing Landscape

The safety-net response to the changing landscape
is varied and evolving. A scan of the field was con-
ducted for this report including a review of literature
and almost 30 interviews with community health
center organizations and associations; public hos-
pital systems including the affiliated county FQHCs;
Medi-Cal managed care plan (MCP) leaders; state
and federal agency representatives; and aging
service and advocacy experts. Findings indicate
important perspectives about how safety-net pro-
viders are responding to changing patient needs
and the extent that these providers have consid-
ered, explored, or enacted adaptations to their
service and business models.

There is a growing awareness among safety-net
providers that patient mix is changing. Among
many safety-net primary care providers, panels of
patients age 45 or older are growing while pedi-
atric age groups are declining or stagnant. Even
so, the implications of this trend and any action to
modify business or operational models has been
largely tempered by the overall higher numbers
of younger patients and the lack of familiarity with
older adult needs and service options. The expan-
sion of specialized services for older patients may
also be constrained by the concern that Medi-Cal
enrollees who age in to Medicare eligibility may
transition to another provider or health plan upon
enrolling in Medicare.

 

California Health Care Foundation

www.chcf.org 6
Care for older adults is an emerging issue for
safety-net associations. The California Primary
Care Association and California Association of
Public Hospitals and Health Systems indicate that
addressing the specific needs of older adults with
low incomes is not currently a top-tier strategic pri-
ority for members. Health centers, public hospital
systems, and Medi-Cal MCPs alike are focused on
implementation timelines for ongoing state policy
initiatives while simultaneously needing to rebuild
basic service delivery infrastructure impacted by the
COVID-19 pandemic and, in some cases, climate-
related events as well.

There are early signs of federal agency aware-
ness and interest. Interviewees from the federal
Bureau of Primary Health Care showed interest in
and awareness of the increasing numbers of older
adults served in the safety net. They are encourag-
ing health centers to explore models for expanding
staffing to increase support for older adults and
aging populations, such as hiring geriatricians,
piloting new strategies to address social deter-
minants of health for older adults, and modifying
payment models to increase quality and reduce
cost for dually eligible older adults.

"We are working internally and with
partners such as CMS [Centers for
Medicare & Medicaid Services] to develop
pilots for different populations, including
the elderly, The movement towards value-
based care could significantly increase
support for currently nonreimbursable
approaches to care coordination and other
patient support services."

- Jim Macrae, associate administrator,
Bureau of Primary Health Care

California policy initiatives are underway to
increase integrated, whole-person care and to
address social needs. Through a set of comple-
mentary initiatives and state budget proposals,
older adults with low incomes will soon have access
to an expanded and more coordinated continuum
of services. There will be increasing numbers of
older adults with Medi-Cal, not only due to demo-
graphic shifts, but also because Medi-Cal eligibility
expanded to include undocumented adults age 50
or older in May 2022.

The pace and scope of change is ambitious. CalAIM
(California Advancing and Innovating Medi-Cal)
represents a set of interrelated initiatives, state
policy changes, and budget resources in service
of its goal to transform the Medi-Cal delivery sys-
tem. The California home and community-based
services spending plan totals $4.6 billion (federal
and state resources), funding efforts across six
state departments to ensure older adults and peo-
ple with disabilities have support to live safety in
the community. Related policy changes and flex-
ibilities, such as efforts to modernize payments to
community FOHCs and flexible reimbursement for
telehealth services, also may influence new models
of care for older adults with low incomes."

Over the next five years, CalAIM sets the stage to
expand managed care and to enhance supports for
older adults with low incomes through a series of
steps:

>» Enhanced Care Management (ECM) and
Community Supports launched in 2022 as a
new benefit (ECM) and new optional services
(Community Supports) through Medi-Cal MCPs,
providing high-touch engagement for high-need
Medi-Cal enrollees and addressing social needs.

> In 2023, dually eligible Californians will be
enrolled in Medi-Cal MCPs statewide for Medi-
Cal benefits.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 7
> Skilled nursing facility care will be integrated as
a Medi-Cal MCP benefit statewide beginning in
2023.

> Statewide availability of aligned Medi-Cal MCPs
and Dual Eligible Special Needs Plans (D-SNPs,
a type of Medicare managed care plan) to coor
dinate all Medicare and Medi-Cal benefits is
proposed by 2026. (Rollout begins in seven
counties in 2023.)

There is uncharted opportunity for community
health centers and public hospital systems to meet
the needs of California's expanding older adult pop-
ulation. The convergence of demographic trends
and policy initiatives aimed at improving coordi-
nation and quality of care for older adults offers a
timely moment for these safety-net providers to
consider opportunities and strategies to expand
services and to improve care for older adults. Given
the central role community health centers and pub-
lic hospital systems already play as major providers
to Medi-Cal MCP members, the potential growth of
MCPs and D-SNPs for dually eligible enrollees rep-
resents an area of future change and opportunity.

Older Adult Population

Needs and Service
Models

Whether seeing significant growth in older adults
or not, a common experience across most safety-
net providers is an increasingly complex patient
population. Meeting the needs of this population
is an increasing focus for community health centers
and public hospital systems. While perhaps not
fully embracing the business and practice consid-
erations specific to older adults with low incomes,
interviewees did report increasing adaptations to
serve adults with higher complexity, such as people
experiencing chronic homelessness. Public hos-
pital systems, in particular, have a long history of

serving high proportions of complex adult patients
and offer compelling clinical models to meet the
needs of these patients. It is useful to consider how
these programs can benefit older adults, given that
the needs and service requirements of older adults
overlap significantly with those of younger and
more complex populations.

Older adults with low incomes present unique
clinical and support service needs that raise mul-
tiple considerations for safety-net providers. This
population can benefit from an increasing array of
supportive services as they age, such as case man-
agement, community health worker assistance,
screening and referrals to address social needs,
eligibility and navigation support, and population-
specific cultural practices. Given these types of
service needs, care models organized to respond
to whole-person needs are especially relevant for
older adults. Comprehensive care models have
historically been the bedrock of community health
centers and public hospitals, making them uniquely
positioned to care for older adults.2' Almost all
FQHCs provide behavioral health services and den-
tal services colocated with primary care, and many
offer pharmacy and optometry services. Nationally,
health centers increased behavioral health staff by
248% over the last 10 years, far outpacing increased
staffing in other clinical positions."

Importantly, the clinical and support service needs
of older adults shift along a continuum as patients
age and become more frail. Common aspects of
care where safety-net providers could evolve to
better support older adults are highlighted in the
sidebar "Older Adult Service Needs" (see page 9),
and examples of how some California safety-net
providers are beginning to address those needs are
described in the next section, "Emerging Practices
and Percolating Innovation."

 

California Health Care Foundation

www.chcf.org 8
Older Adult Service Needs

> Longer appointment slots

> Increased need for physician visits, including
from internal medicine physicians and
geriatricians

>» Chronic disease management

> Care management services

> Access to aligned specialty services, podiatry,
cardiology, physical therapy, endocrinology,
gastroenterology

» Aligned ancillary services, such as pharmacy
and imaging

> Behavioral health services

> Dental services

> Polypharmacy / medication reconciliation

> Targeted support, such as transportation,

isolation-reducing services, partnership with
housing programs

Care model. As patients age or have more complex
needs, the core primary care model must evolve,
including who provides primary care, how services
are structured, and how to expand care coordina-
tion, care management, and support services for
social needs. Primary care for older adults becomes
more physician dependent and may require longer
appointment times due to the prevalence of mul-
tiple chronic conditions, cognitive impairment, and
other disabilities.

Clinical services. Beyond primary care support,
older adults require and use a more comprehensive
range of clinical services. Dental and behavioral
health services are a particular need among older
adults with low incomes and are offered in most
community health centers. A broad array of com-
plementary clinical specialties, such as podiatry,
cardiology, physical therapy, endocrinology and
gastroenterology, behavioral health, dental ser-
vices, medication reconciliation, and links to home

health and long-term services and supports are also
important.

Support services. Care coordination for older
adults is an essential and intensive service to sup-
port effective navigation across multiple providers
addressing medical, dental, behavioral health,
long-term services and supports, and social needs.
As patients age, support services outside traditional
health care are essential. Providers must organize
a range of supports, whether through community
partnerships or internal services, to meet the needs
of older adult patients. These supports include ser-
vices such as Medicare enrollment, transition and
navigation support, transportation, programs to
increase social connections and reduce isolation,
services to address food insecurity, and support for
housing and social services.

Service settings. The prevalence of functional or
mobility limitations among older adults means that
providers should consider the settings and facilities
where they deliver care to this population. This may
mean redesigning waiting rooms, exam rooms, and
other clinic settings to be physically and socially
welcoming for older adults. The equipment and
facilities to accommodate older adults with limited
mobility include powered, accessible exam tables
and larger corridors and rooms for easy wheelchair
use. Older adults can often benefit from the use of
remote monitoring and telehealth services, although
support may be required to use these services.

Market expansion. Some safety-net providers
are examining the local Medicare marketplace
to explore ways to retain patients and reach new
patients. Providers describe scanning for the market
penetration of Medicare Advantage (MA) and iden-
tifying local plans, determining the level of Medicare
fee-for-service (FFS), assessing patient needs and
market gaps, and developing a strategy that aligns
MA contracting and patient recruitment. As adults
age in to Medicare, they typically receive myriad and

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 9
confusing communications from government pro-
grams, health care systems, and health plans. Taking
initiative to raise awareness that older adult patients
can stay with their safety-net provider after Medicare
enrollment, coupled with support for Medicare
enrollment through trained staff and relationships
with insurance brokers, are underutilized "low-hang-
ing fruit" patient retention strategies for safety-net
providers. The recent Medi-Cal expansion to undoc-
umented adults age 50 or older is yet another factor
for considering expansion of safety-net providers'
efforts to attract and retain older adults.

Emerging Practices and
Percolating Innovation

Promising strategies and models of care tailored to
older adults with low incomes have begun to per-
colate across the California safety net, building on
the strengths and history of safety-net providers.
Practices span the continuum of care for the most
frail and vulnerable adults of all ages, to adapted
primary care strategies for older adult patients with
lower acuity and social needs. Given the demo-
graphic, health care utilization, and policy trends,
planning for a deeper and broader response to the
needs of older adults may be a strategic imperative
for safety-net providers over the coming years.

The range of approaches described below high-
lights varying local context and organizational
capacity to provide services along the continuum of
needs for older adults.

Older adult clinics are not explicitly organized to
serve the frail elderly; rather, they target both adults
age 50 or older, as well as people with complex
conditions. These programs include internal medi-
cine or family practice physicians focused on the
care of adults linked to aligned specialty services,
social supports, care management, and facilities
conducive to care for this population.

Preparing for Anticipated Growth of
Older Adult Population

Marin Community Clinics (MCC) serves residents
with low incomes in one of the fastest aging
counties in California. In anticipation of the need
to serve growing numbers of older adults with
low incomes, MCC opened a clinic site explic-
itly designed to attract and serve adults age 50
or older. The new site pairs internal medicine
with select specialty services, allows for longer
appointment times, has waiting rooms and exam
rooms and tables conducive to older adult needs,
delivers targeted enabling services (e.g., trans-
portation), and uses aligned site promotion and
marketing strategy to appeal to the older adult
community.

Geriatric clinics operate as separate, comprehen-
sive primary care programs staffed by a team usually
led by a geriatrician or internal medicine physician
and designed to serve higher acuity older adult
patients with longer appointments, specialized
equipment and senior-friendly facilities, intensive
case management, and other support services.
Geriatric clinics can serve as a next step on the con-
tinuum of care after older adult clinics.

Care coordination and management linked
to social needs and services - including pop-
ulation health management, __risk-stratified
empanelment, and multidisciplinary and home-
based care approaches - are essential for older
adult services. One payment source for these ser-
vices is the Medicare Chronic Care Management
(CCM) benefit, available within fee-for-service
Medicare. CCM provides additional reimburse-
ment to providers caring for people with two or
more chronic conditions in recognition of the time
required to assess needs, coordinate services, and
provide education to support managing chronic
medical conditions. CCM services can support
addressing some clinical care coordination needs

 

California Health Care Foundation

www.chcf.org 10
for older adults but may not enable providers to fully
meet social needs. While some FOHCs have chosen
to operate CCM using in-house staff and resources,
several community FOHCs noted that their health
centers lacked the care coordination, staffing, and
billing capabilities to advance CCM. They turned
to an external vendor contract to deliver CCM and
have been pleased and surprised with the interest
in the program expressed by patients.

Embedded Care Coordination Services
Adults age 65 or older account for more than
20% of patients at the North East Medical Ser-
vices (NEMS), an FQHC in San Francisco. NEMS
operates an embedded care management model
for older and higher-risk patients, including risk-
stratified patient panels (by age and gender), an
enterprise-wide population care management
team, and complementary care coordination and
behavioral health management teams. NEMS also
offers PACE (Program of All-Inclusive Care for the
Elderly) to enable nursing home-eligible patients
to live in the community safely and indepen-
dently. Looking forward, NEMS aims to expand
remote patient monitoring and other technology-
enabled solutions. They anticipate opportunities
to leverage their in-house independent practice
association (IPA) and pursue a limited Knox-
Keene license to operate a health care service
plan to widen resources and tools to care for their
patients.

Medication reconciliation programs work to
combat use of nonbeneficial medications and to
identify potential medication interactions and side
effects that can be especially dangerous for older
adults. Older adults metabolize drugs at different
rates than younger adults and are more prone to
drug interactions, given multiple chronic conditions
and, frequently, prescribing by multiple special-
ists. Through medication reconciliation programs,
a health center pharmacist or primary medical

provider holistically reviews pharmaceuticals for
older patients at least once per year. Patients are
asked to bring in all medications to discuss how
they are using each one, identify possible interac-
tions between medications, and adjust dosages or
change medications.

Enhanced technology is a growing and important
component of care for older adults. Technology
capacities include more fully using existing elec-
tronic health record patient portal and population
management capabilities, expanding the use of
remote monitoring to manage chronic health condi-
tions without in-person visits, and targeted reliance
on telehealth visits for older adults. Considerations
related to training and support for older adults to
make effective use of technology is considered best
practice.

Medicare enrollment assistance that includes nav-
igation and enrollment support as patients age into
Medicare coverage is a growing practice in com-
munity FOHCs that helps patients and supports
continuity of care, while encouraging the patient to
remain with the FQHC. Health centers that define
retention of patients aging in to Medicare as a goal
find there is an increase in older adult patients and
reimbursement that serves as rationale to invest in
this assistance.

"That is one of the biggest problems
with retaining our Medicare patients in
community health centers. When our
patients reach Medicare eligibility, we
don't do enough to retain them while the
Medicare Advantage plans are aggressively
marketing to them."

- Kevin Mattson, CEO, San Ysidro Health

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 11
Medicare Enrollment and Retention
Several health center interviewees shared
examples of strategies they are using to increase
retention of patients as they age in to Medicare:

> Assign low-intensity but high-touch navigators
to outreach, assist with enrollment support and
provider selection, and periodically touch base
during the first year of care following the Medi-
care transition.

> Conduct outreach and education, includ-
ing "64th birthday" mailings, monthly on-site
birthday parties and appreciation events, and
events at neighborhood grocery stores to meet
with on-site eligibility specialists or independent
Medicare insurance brokers.

» Establish relationships to educate independent
brokers about the health center and to provide
space on-site for cooperative independent
brokers to meet with patients.

> Expand training of staff benefit consultants to
support Medicare enrollment for patients and
Medicaid enrollment for those Medicare-cov-
ered patients not already on Medicaid.

Primary care at home can be beneficial for some
older adults with chronic conditions and functional
disabilities. Research indicates these programs fill
gaps in care and can be cost-effective by reducing
hospitalizations and skilled nursing care."? Primary
care at home may also be an effective option for
attracting and retaining disabled older adults with
low incomes because the services are highly valued
by patients. Primary care at home can be reim-
bursable if the patient cannot get to the clinic. In
addition, providing these services may be part of an
overall cost containment strategy under managed
care or other risk-bearing arrangements where
the health center benefits by reducing the overall
cost of care." Lifelong Medical Care and several
other centers report operating a primary care at

home program using a team of physicians, nurse
practitioners, and case managers, augmented with
home-based palliative care when needed. Health
centers also report providing health services to
patients in skilled nursing facilities and other con-
gregate housing settings.

PACE (Program of All-Inclusive Care for the Elderly)
is a full-risk capitated program of comprehensive
services to maintain independence for older adults
who would otherwise require institutional care.
With full financial risk, PACE can generate meaning-
ful margins but can also expose the organization to
potential losses. PACE is an entirely distinct line of
business for safety-net providers requiring new facil-
ities, services and providers, and administrative and
business infrastructure that translates into start-up
costs of several million dollars. The longer-tenured
PACE programs at FOQHCs report consistent pro-
gram growth and positive financial margins. PACE
may serve as a natural extension of the continuum of
care for safety-net providers with large older adult,
dually eligible populations. For smaller health cen-
ters lacking economies of scale to engage in PACE,
partnerships with other FOHCs may be a pathway
to provide PACE services. Expansion of PACE by
FQHCs is underway throughout parts of Northern,
Central, and Southern California.

Geriatric emergency rooms in hospital settings
have adapted staff models, facilities, and care pro-
tocols, similar to models of separate pediatric and
psychiatric emergency settings. Staff have geriat-
ric training, use protocols to screen for cognitive
impairment, and operate in a space designed for
older adults by reducing ambient noise and dis-
traction. This is an emerging practice intended to
improve the experience and care for older adults
whose chronic conditions can mean more frequent
emergency room visits.

 

California Health Care Foundation

www.chcf.org 12
Clinical and Business
Model Considerations

Most safety-net organizations have yet to invest in
specific older adult services. While a few providers
are setting the pace for fully integrated business
and programmatic strategies to serve older adults
with low incomes, others are at the start of assess-
ing future options for programs, taking initial steps
to expand services, or developing an understand-
ing of the implications of changing community
needs for their role as service providers.

Stepping more intentionally into care for older
adults presents new business and financial con-
siderations and potential opportunities. Safety-net
providers have well-defined financial models that
currently rely heavily on per visit Medicaid and
Medicare prospective payment system (PPS) reim-
bursement for FOHCs and supplemental Medicaid
financing for public hospital systems. Expanding to
specialized care models for older adults with low
incomes, including both dually eligible enrollees
and adults with Medicare only, requires new cal-
culations for productivity and reimbursement, an
approach to risk and managed care arrangements,
understanding of market share and patient recruit-
ment, and analysis of the role and value of new or
different lines of business.

Strategic foresight. A few safety-net providers
have acknowledged the increasing numbers of
older adult patients and recognize this trend will
continue. For this group, it is clear that the safety
net is well positioned to offer integrated social
and clinical care and that there is strategic value
in developing integrated financial, service, and
business strategies at the organizational level to
attract and retain older adults with low incomes.
These providers have adopted varied approaches
based on local context and organizational vision
and demonstrate a willingness to leverage man-
aged care and expand risk as a part of their older

adult strategy. For example, some providers are
participating in risk-based contracts through IPAs
to maximize value-based payments. A few health
center organizations operate or are developing
PACE services and incorporating clinical and long-
term services and supports to allow those who
would otherwise require institutional care to remain
safely in the community. Others are contracting with
Medicare Advantage (MA) plans, actively recruiting
MA enrollees, offering Medicare enrollment sup-
port, and maintaining relationships with local health
insurance brokers.

Expanding the Continuum of Care for
Older Adults

AltaMed, based in Los Angeles, is a large FOHC
serving more than 325,000 patients. AltaMed has
long-standing experience delivering PACE ser-
vices. Primary care for older adults, however, has
been embedded within general medicine clinics
and teams. More recently, internal leadership is
taking a different view. "The fact is that we recog-
nize that PACE is in a continuum. We want to be
able to offer that middle part of the journey, which
is why the senior clinic strategy becomes so criti-
cal," says Lourdes Birba, vice president of Aging
Services and Product Development. AltaMed is
adapting its care model across the enterprise to
incorporate longitudinal care management, trans-
formed care teams, longer appointment times,
and programmatic tiering based on need and
complexity. AltaMed is initiating separate older
adult medicine clinics at two sites, to be expanded
based on experience.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 13
Deliberate movers. A second group of safety-net
providers is making steady progress to deepen
and expand services for increasingly complex and
aging patients. Interviewees in this group flagged
incremental steps across a range of strategies to
increase the number of older adults served, such
as implementing older adult clinics, conducting a
feasibility plan for PACE, expanding in-house spe-
cialty services, and hiring geriatric provider staff. In
addition, interviewees mentioned steps to evalu-
ate facility and equipment to match the needs of
older adults, as well as strengthening knowledge
and expertise to maximize billing, contracting, and
financial performance. Some FOHCs are estab-
lishing MA contract relationships and Medicare
Chronic Conditions Management (CCM) contracts
for traditional (fee-for-service) Medicare patients.
Still others are conducting outreach to patients
aging in to Medicare.

Chronic Care Management

The far northern California communities served

by Shasta Community Health Center (SCHC) have
been home to more older adults than many other
California communities. To meet local needs, the
clinical model for SCHC leans more on physi-

cian providers than many FQHCs. Competing
demands and constant workforce shortages have
limited programmatic attention on older adults. In
the last year, however, SCHC secured a contract
with an outside vendor to manage the Chronic
Care Management (CCM) program, a reimburs-
able care coordination benefit for Medicare FFS
enrollees. The program, which has attracted signif-
icant patient participation, provides phone-based
assistance and navigation. "The navigational
aspect of this is what people are really welcoming.
They are having difficulty connecting to some of
the resources, and this helps," stated Dean Ger-
mano, CEO of Shasta Community Health Center.

At the starting line. A third and larger group of
organizations has yet to elevate the strategic impor-
tance of an older adult strategy or simply lacks the
bandwidth to develop new capacities. Rural health
centers interviewees noted they have historically
served large older adult populations. For example,
the majority of health centers in rural Northern
California (12 of 15) report that 15% of total patients
served in 2020 were age 65 or older." But many of
these organizations face multiple challenges and
workforce shortages that make it more difficult to
take significant steps to expand care or to imple-
ment new business strategies for older adults in the
immediate future. Some acknowledged putting their
efforts to increase older adult services on hold in the
face of a steady stream of crises over recent years.

Many community health centers and public hospital
systems recognize that it takes effort and planning
to understand local trends, explore the business
drivers, and develop the relevant organizational con-
siderations before any strategy implementation for
older adults with low incomes. Although the immedi-
ate future may be challenging, beginning a dialogue
with community-based aging organizations, elder
advocates, and community leaders may offer an
opening for incremental steps forward. Interviewees
also raised a partnership model with other safety-net
providers as a viable option to address the lack of
scale that is a barrier for some providers to sustain
services for older adults with low incomes.

"FOHCs need to be looking at the
demographics in their community to

see how it is changing and to better
understand what the demographics are
showing. The second important thing is
looking at their operations and capabilities
to treat an older population."

- Jim Macrae, associate administrator,
Bureau of Primary Health Care

 

California Health Care Foundation

www.chcf.org 14
Public hospital systems as clinical leaders. Public
hospital representatives highlighted a long history
of serving patients age 25 to 64 with multiple and
complex needs. However, most of these interview-
ees indicated their organization does not have a
corresponding strategic or business focus specific
to older adults. In part, this is related to complex
financing issues, discussed in the "Public hospi-
tal systems" subsection on page 17. Maximizing
revenue through funding streams tied primarily to
Medi-Cal, such as supplemental payments provided
to hospitals serving a high proportion of Medicaid
and uninsured patients, is a significant driver of the
way services are delivered and impacts organiza-
tional strategy. Representatives from most public
hospitals interviewed indicated they do not have
MA contracts, and as a result, patients that age in
to Medicare and enroll in an MA plan must change
providers. Public hospitals systems also recognize
that supplemental payments are unsustainable,
and they need a stronger, more secure financial
footing - which could be fostered in part through
changes to payer mix.

There however.
Interviewees noted that even without an articu-
lated older adult business strategy, they maintain
a small and steady role in older adult care and are
clinically well suited to do more. Public health care
systems often have expansive internal medicine
and geriatric clinical staff and a track record serv-
ing adults with low incomes experiencing complex
health and social needs, such as homelessness and
serious mental illness. As integrated systems of
outpatient, inpatient, primary, and specialty care,
public hospitals can develop multiple elements of a
continuum to attract older adults with low incomes,
including many of the models described above.
Some public hospitals, including Zuckerberg San
Francisco General Hospital and Trauma Center,
have participated in efforts to improve the quality
and experience of older adults by developing geri-
atric emergency departments. Through training,

are pockets of innovation,

residency rotations, leadership opportunities, care
management practices, and facility improvements,
geriatric emergency departments provide age-
friendly care and transition services after discharge
from emergency care to reduce the number of hos-
pital readmissions post-emergency.

Complex Care in Public Systems
Zuckerberg San Francisco General Hospital and
Trauma Center (ZSFGH) has an ambulatory care
service model in their clinics responsive to the
needs of more complex populations, including
older adults. This includes complex care manage-
ment, behavioral health, and social workers. Susan
Ehrlich, MD, CEO of ZSFGH, noted, "The services
that we have already incorporated into our care
model to address complex social, behavioral, and
medical needs are critically important for older
adults." ZSFGH was also the only public hospital
system interviewed that reported that it is on the
path to becoming certified as having a geriatric
emergency department.

Outpatient productivity and reimbursement. For
FQHCs, traditional financial sustainability is rooted
in Medi-Cal as the primary payer, relying on clinical
productivity and a cost-based PPS rate sufficient to
sustain needed services. FQHCs receive full Medi-
Cal PPS rate reimbursement for dually eligible
patients. Visits for Medicare-only patients are reim-
bursed at the Medicare PPS rate, which is less than
the Medi-Cal PPS rate. Older patients present with
more complex needs, resulting in lower clinical pro-
ductivity and increased care coordination that PPS
rates may not fully cover. According to interviewed
health center leaders and available data, most
FOQHC patients age 65 or older are dually eligible,
but this can vary by community. Rural health centers
serve a broader segment of the older adult com-
munity than their urban counterparts, which means
more Medicare-only patients.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 15
Care models and services for older adults also
present new opportunities for generating revenue.
As the proportion of Medicare and dually eligible
patients grows, health centers will be increasingly
pushed to reevaluate reimbursement strategies,
deepen Medicare billing and financial expertise,
and leverage multiple revenue sources. Some
options include:

> Implementing Medicare CCM to gain reim-
bursement for care coordination for older adults
enrolled in FFS Medicare via an internal staffing
or outsourcing model.

> Leveraging FOQHC pharmacy revenue through
the 340B Drug Pricing Program to enhance over-
all revenue, given that medication prescriptions
are notably higher among older patients. The
340B Drug Pricing Program allows eligible health
care clinics and hospitals to purchase outpatient
drugs at a 20% to 50% discount and to reinvest
savings into expanded clinical programs.

>» Expanding MA contracts with competitive capi-
tation rates and Star Rating quality incentives
that strengthen sustainability. Some health cen-
ters are elevating their contracting and billing
office expertise to understand and leverage
these opportunities. With a large enough MA
panel, health centers are in a better position to
negotiate favorable MA contracts including risk-
sharing arrangements.

> Forming a continuum of approaches with an
overall revenue strategy. For example, older adult
clinics or geriatric clinics may serve as meaningful
sources for referrals into health center-led PACE
programs. Within public hospital systems, out-
patient clinics may serve as attractive feeders to
specialty or hospital services. New lines of busi-
ness, such as PACE, can present strong revenue
generation that offset other outpatient losses.

Managed care and risk. The role of managed care
in serving older adults with low incomes is expected
to increase over time, as CalAIM requires Medi-Cal
managed care plans to offer D-SNPs available to all
dually eligible enrollees by 2026. Although the time-
line may shift, the long-term intention of increasing
enrollment in aligned Medi-Cal and Medicare plans
appears clear. This represents a natural opportunity
for safety-net providers already central in Medi-Cal
managed care networks.

California's diverse communities vary in the por-
tion of their Medicare populations enrolled in MA
and those remaining in FFS. Local prevalence of
MA alongside provider interest and expertise in
managed care risk defines the relevance of this
marketplace for safety-net providers. Some provid-
ers are exploring aligned managed care and risk
strategies for older adult services to incorporate the
additional costs of care coordination into revenue
and also to improve health outcomes. This includes
using health center-controlled IPAs and networks to
contract for Medicare lines of business, which can
contribute positive net income that may be used
for expanded and more flexible services for enroll-
ees. Whereas Medicare accounts for a small subset
of safety-net patients currently and thus often does
not merit significant organizational attention and
resources, the strategic importance of managed
care and risk strategies may increase in safety-net
systems as the number of Medicare patients grows
and networks evolve.

 

California Health Care Foundation

www.chcf.org 16
Public hospital systems. Public hospital systems
face unique challenges around Medicare reim-
bursement due to their dedicated resource streams.
California public hospital operations and systems
are designed to maximize Medi-Cal reimbursement,
track and report supplemental payments provided
to hospitals serving a high proportion of Medicaid
and uninsured patients, and maintain their mission
to serve primarily Medi-Cal and uninsured patients.
Often these are not the same strategies required
to participate at scale in Medicare risk-based
reimbursement.

Likely in response to multiple factors, including
supplemental payments and Medi-Cal waiver
funding, historical service patterns, and internal
strategic choices, California public hospitals have
not prioritized services to dually eligible enrollees
and other Medicare enrollees and often report no
financial advantage in any available Medicare rev-
enue options. Despite the dedicated clinical staff
and history with socially complex patients, inter-
views did not reveal specific business or financial
strategy to translate these existing strengths into
a focused area of growth for the expanding older
adult population. There are indications from some
public hospital leaders that the time has come for
modifying this position, as recent trends indicate
rising percentages of patients age 60 or older. In
addition, the current reliance on specialized funding
streams, like supplemental payments, may decline
as more older adults served by public hospitals are
enrolled in managed care, and public systems are
considering how a move to capitation will change
operations and revenue streams. Diversifying their
payer mix, including dually eligible enrollees, may
provide more sustainable and stable sources of
funding over time.

Changing the operational and clinical care models
honed for success under current reimbursement
policy will require lead time, different accounting
supports, and perhaps a new context for defining

provider productivity. One public hospital leader
noted they recently purchased cost-accounting sys-
tems that will track productivity and costs for the
first time.

Interviewees spoke to internal shifts toward strategy
to build expertise and systems that will retain dually
eligible enrollees, initiate risk-based Medicare con-
tracts, and tailor services to the needs of older
adults with low incomes. Public hospital representa-
tives also referenced the expansion of Medi-Cal to
older undocumented adults as a shift that may spur
rethinking of multiple dynamics.

Public hospital systems have financial expertise,
administrative resources, and clinical depth that
position them well for success. They also may
have untapped resources for building new service
models in underutilized facilities and campuses no
longer in service and often in communities where
older adults live.

Taking stock. Financial and risk strategies are
undergoing change, and the resulting impact is
not yet clear. In the near term, some health centers
are likely to move from prospective payment sys-
tems to a new alternative reimbursement method,
and the future of public hospital reimbursement is
also under scrutiny. As California's safety-net care
delivery landscape evolves in coming years, stake-
holders concerned with providing high-quality
health care and supports to older adults with low
incomes should consider the following questions:
How will future policy and reimbursement intersect
with demographic trends and changing patient
populations? How will safety-net providers succeed
under new benefits and services while retooling
billing and financial systems? And perhaps most
important, how will multiple, simultaneous system
changes impact the ability of providers to innovate
and expand programs for the growing older adult
population?

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems 17
Looking Forward

This report documents demographic, health care
utilization, and policy trends to elevate the growing
need and opportunity to expand targeted and tai-
lored care models for older adults with low incomes
in community health centers and public hospital
systems. There are multiple care models and service
options to consider, and safety-net providers should
explore them within the local health and social ser-
vices context before proceeding. Below, four steps
are outlined to guide analysis and decisions about
various older adult services and alternatives.

Community assessment. Conduct a local scan and
data analysis to gain an understanding of the exist-
ing continuum of services and to assess data about
older adults with low incomes at the zip code level.
This will offer a big picture view of the current size,
projected characteristics and the associated needs
of local populations of older adults and older adults
with low incomes.

Business assessment. Research the current
local health care market for older adults with low
incomes, including the number of MA plans in the
area and the provider networks associated with
each plan. The findings will inform an analysis of
financial and operational options. Learning about
existing and planned D-SNPs is perhaps more chal-
lenging to uncover yet is critical to future revenue
analysis. Identifying and developing relationships
with other community organizations supporting
older adults may offer insights into the needs and
gaps in the current system. Finally, insurance bro-
kers providing Medicare navigation may be another
source of information about the patterns and busi-
ness arrangements in place locally. Making sense of
the organizational players and financial contracting
options currently and into the future are important
elements of assessing the overall opportunity.

Organizational capacity. A separate, internally
facing assessment should consider organizational
capabilities and gaps for various service models
and scenarios. A careful assessment of the clinical,
business, and strategic alignment that might be
required to expand discrete program elements or
launch totally new lines of business to serve older
adults is likely a team exercise across multiple
departments of the organization. It may require
underlying assessment of workforce challenges,
financial position, experience with risk-based con-
tracts, and whether the organization has recently
launched other strategic initiatives.

Phased approach. For many of the emerging prac-
tices identified, starting small and building expertise
over time is a good practice. This approach can
focus on services or programs that may be newly
targeted to older adults but are within established
organizational capacities, such as Medicare enroll-
ment. Unless significant capital is available and
a specific clinical and business strategy has been
identified, options that expose the organization to
risk, such as a PACE program, are best launched
after a period of experience.

 

California Health Care Foundation

www.chcf.org 18
Conclusion

Community health centers and public hospital sys-
tems have an important role to play in the care of
older adults with low incomes. California policy and
rapidly changing demographics are key drivers of
opportunity to supporting the integration of ser-
vices needed for older adults to live safely in the
community. The growing number of older adults
served in safety-net systems offers a compelling
case for health centers and public hospital to assess
and expand services dedicated to older adults
with low incomes by building on core capacities
for complex clinical, behavioral, and social needs.
Many safety-net providers have begun to respond
with innovative practices that marry their strengths
to the rapidly changing demographics and contrib-
ute positively to the care available for older adults.
Primary care that incorporates technology and
seamlessly links social supports is a logical fit for
health centers.

An aging and diverse California calls for safety-net
providers to respond and grow as critical providers
of care for older adults with low incomes. Forging
stronger alliances and shared purpose between
advocates for older adults, policymakers, and health
centers with interest in developing more extensive
models of care may serve to accelerate progress.
By working together, these stakeholders can ensure
that the existing strengths of safety-net providers -
such as cultural and language capacity, integrated
medical, behavioral health, and oral health services,
team-based models of care, and other services to
address social needs - are employed to deliver a
system that supports health and well-being for an
older and more racially diverse California.

 

Improving Care for California's Older Adults: The Role of Community Health Centers and Public Hospital Systems

19
Endnotes

1.

10.
11.

12.
13.

14.
15.
16.
17.

Jen Joynt, Long-Term and End-of-Life Care in California,
2020: Is California Meeting the Need?, California Health
Care Foundation (CHCF), June 2020.

. "Facts about California's Elderly," California Dept. of Aging.
. Long-Term and End-of-Life Care, CHCF.

. Nina Ebner and Nari Rhee, Aging California''s Retirement

Crisis: State and Local Indicators (PoF), UC Berkeley Labor
Center, October 2015.

. "Appendix G," in California State Plan on Aging, 2017-

2021 (PDF), California Dept. of Aging.

. "Office of Medicare Innovation and Integration: Data

and Information," California Dept. of Health Care Services
(DHCS), last updated February 2022; Amber Christ and
Georgia Burke, A Primer on Dual-Eligible Californians: How
People Enrolled in Both Medicare and Medi-Cal Receive
Their Care, CHCF, September 2020; and author analysis

of 2014 and 2019 Health Center Program Uniform Data
System (UDS) Data Overview from the US Health Resources
and Services Administration. While UDS data from 2020
were reviewed for this report, due to the multiple impacts of
the COVID-19 pandemic on health care use and delivery in
2020, this report presents 2014-19 data as a more reliable
comparison period for analysis of trends.

. Author analysis of UDS data.
. Author analysis of UDS data.
. Author analysis of UDS data.

Author analysis of UDS data.

Author analysis of California hospital patient discharge

data from 2014 and 2019 from "Hospital Inpatient -
Characteristics by Facility (Pivot Profile)," California Health
and Human Services Open Data Portal.

Author analysis of California hospital discharge data.

Sandra Decker, "CHCs and the Health Care Safety

Net - Dual Eligibles and Those Medicaid-Eligible Due
to Disability Are Most Likely to Use Community Health
Centers" (APPAM 42nd Annual Fall Research Conference,
online, Nov. 11-13, 2020).

"Office of Medicare Innovation and Integration," DHCS.
Author analysis of UDS data.
Christ and Burke, Primer.

Tara A. Lavelle et al., "Utilization of Health Care

Services Among Medicare Beneficiaries Who Visit
Federally Qualified Health Centers," BMC Health Services
Research 18, no. 41 (Jan. 25, 2018).

18.

19.

20.

21.

22.
23.

24.
25.

Author analysis. Diabetes: Diabetes population with

HbA1c under control (HbA1c <= 9%); Hypertension:
Hypertension population with blood pressure under control
(<= 140/90 mmHg); California HEDIS: Statewide Medi-Cal
managed care weighted average performance measure
results; FQHC source: author analysis of UDS data; and
HEDIS source: Medi-Cal Managed Care External Quality
Review Technical Report, July 1, 2018-June 30, 2019 (PpF),
vol. 1, Main Report, DHCS, June 2020.

Melony E. Sorbero et al., Addressing Social
Determinants of Health Needs of Dually Enrolled
Beneficiaries in Medicare Advantage Plans: Findings
from Interviews and Case Studies, RAND Corp., 2018;
and Charron L. Long et al., "Health-Related Social Needs
Among Older Adults Enrolled in Medicare Advantage,"
Health Affairs (Millwood) 41, no. 4 (Apr. 2022): 557-62.

Time to Modernize Payment to Health Centers:
How Old Rules Jeopardize Patients During the COVID-19
Pandemic, CHCF, June 2020.

Community Health Center Chartbook, National
Association of Community Health Centers (NACHC), 2021.

Chartbook, NACHC.

Christine Ritchie et al., Medical Care at Home

Comes of Age, CHCF, January 2021; and Sarah Klein,
Martha Hostetter, and Douglas McCarthy, An Overview
of Home-Based Primary Care: Learnings from the Field,
Commonwealth Fund, June 2017.

Ritchie, Medical Care at Home.

Author analysis of UDS data.

 

California Health Care Foundation

www.chcf.org 20