Aw

CHCF

INNOVATION LANDSCAPE SERIES

 

MARCH 2022

by Nigel Smith, MBA

Medi-Cal and Opportunities for Health Tech in
Home-Based Medical Care

usual model of going to the clinic or hospital for

care does not always work well.' Home-based
medical care programs have been designed to fill
this gap, providing better care to people living with
multiple chronic conditions, functional limitations, and
often social risk factors who have difficulty accessing
care in traditional settings.

- or people living with complex health needs, the

This group, which includes seniors as well as younger
people living with physical, mental, or developmen-
tal disabilities, is large. The state's Medicaid program,
Medi-Cal, plays an outsized role in covering their care.
Although Medi-Cal covers one in three Californians, it
covers more than 50% of those living with a disability."
In fact, there are 2.1 million seniors and people with
disabilities covered by Medi-Cal, who represent
roughly one in seven Medi-Cal enrollees.? The senior
population in particular is quickly growing, with peo-
ple age 75 and older representing the fastest growing
demographic segment in California.*

Medical services provided in the home can result in
better outcomes, lower costs, and higher satisfaction
for patients and their caregivers, and there is evidence
of these improvements with home-based models.® The
benefits are most pronounced for patients with the
most complex and overlapping needs. The COVID-19
pandemic reinforced this demand and underscored
the importance of equitable access to these services.

Growing demand from consumers and their care-
givers and a favorable policy environment create an
opportunity for entrepreneurs and safety-net plans
and providers to work together to improve access to
these innovative models.

 

What Is Home-Based Medical Care?

Home-based medical care is care that is pro-
vided where one lives and can be longitudinal
or episodic. Longitudinal care is continuous
care over an extended period, such as home-
based primary care, home-based medical
comanagement models, integrated medical/
social models, and home-based palliative
care. Episodic care is primarily confined to a
single incident or time-limited episode of care
over days to weeks and includes community
paramedicine / acute in-home, hospital-at-
home, and transitional care models.®

Read more about home-based medical care
in CHCF's report Medical Care at Home
Comes of Age.

 

 

 

Opportunities for Innovation

Seniors and people with disabilities are more likely
to use acute services. Some of these acute services
could be replaced with care delivered in the commu-
nity. Seniors and people with disabilities are almost
twice as likely to use the emergency department and
nearly six times as likely to be admitted to the hospital
as other people with Medi-Cal coverage.' Being hos-
pitalized can lead to greater frailty and disorientation
and is expensive.®

In addition to complex medical needs, seniors and
people living with disabilities often have func-
tional impairments, and need help with bathing,
dressing, taking transportation, or managing their
medications. Enrollees eligible for both Medicare
and Medi-Cal (dually eligible enrollees) are more likely
than their Medicare-only counterparts to have a con-
dition resulting in a functional limitation or disability,
including, for example, mobility impairments, intellec-
tual disabilities, dementia, depression, anxiety, bipolar
disorder, and schizophrenia.' These functional impair-
ments often make it difficult for them to access care in
traditional settings outside the home.

Seniors and people with disabilities with low
incomes often face additional challenges, like
food insecurity and social isolation that need to
be addressed to support health and healing.'° The
most common social risk factors reported by a sample
of managed care plans that offer both Medicaid and
Medicare benefits include housing instability, lack of
access to transportation, food insecurity, as well as
social isolation and loneliness.'' These needs are addi-
tional barriers to getting care and managing chronic
illness and can result in higher rates of hospitalization.'

"In the home, it's very eye-opening. You
see the fall risk, the empty fridges, the
lack of support. Then it makes sense, and
you address those things which you would
never know about in your post-discharge
appointment, and they get better."

- Mike Le, Landmark Health

Reimbursement Challenges
Abound

While demand for home-based medical care is grow-
ing, access to it remains limited. Outside of the
Program of All-Inclusive Care for the Elderly (PACE), a
home- and center-based care program with a unique
reimbursement model that delivers fully integrated
social and medical care, reimbursement pathways
for home-based medical care are complicated. More
information on PACE is provided in the Innovation in
Action section at the end of this paper.

Fragmented accountability and financing. Many of
the people that would benefit from home-based med-
ical care are dually eligible. For them, Medicare pays
for physician and hospital services, prescription drugs,
short-term postacute care (in the home or at a skilled
nursing or rehab facility), and medical equipment
needed in the home (e.g., walker, oxygen equipment).
Medi-Cal, on the other hand, pays for long-term nurs-
ing home care, transportation, medical equipment
needed outside the home (e.g., power wheelchair)
or that is disposable (e.g., incontinence supplies),
and other services that support independent living
(e.g., personal care services). Providers, particularly
those seeking to provide integrated, whole-person
care, may need to contract with both Medicare and
Medi-Cal. Less than 10% of people eligible for both
are enrolled in a managed care plan that combines
both Medicare and Medi-Cal coverage, so for provid-
ers caring for the more than 90% without integrated
plans, contracting is complicated.' In addition, while
about 70% are enrolled in a Medi-Cal managed care
plan, some important Medi-Cal benefits, like per-
sonal care services, specialty mental health services,
substance use services, and services for people with
developmental disabilities are carved out of Medi-Cal
managed care and managed by counties or regional
centers.

 

California Health Care Foundation

www.chcf.org 2
Low fee-for-service reimbursement requires
value-based payment. For seniors and people with
disabilities enrolled exclusively in Medi-Cal, there is
no fragmentation for physical health care services, but
reimbursement levels are very low, presenting a real
barrier to adoption. Alex Foxman, president of Mobile
Physician Associates, summarizes this pain point well:
"Medi-Cal reimbursement is 30% of Medicare, and
without a capitation attached, it would be impossible
to provide our level of service to Medi-Cal patients."
Value-based models have emerged as the preferred
payment path, with most of the home-based medical
care service providers pursuing per-member per-month
capitation and shared savings pathways. Value-based
payments can help with low fee-for-service rates in
two ways. Capitation can enable team-based care,
where more of the care is provided by lower-cost team
members who do not have the licensure to bill on their
own. Value-based payments can include shared sav-
ings, where savings from avoided hospital and other
costs are shared with ambulatory providers, helping
to offset low rates. These models can be complicated
and become more so with the attribution of savings
across benefits split between Medicare and different
aspects of the Medi-Cal system.

Regulatory Tailwinds

CalAIM and Home- and Community-
Based Spending Plan

The reform elements included in the CalAIM (California
Advancing and Innovating Medi-Cal) initiative and the
home and community-based services (HCBS) spending
plan should reduce the barriers to adoption. These
reforms offer the potential to increase system integra-
tion and coordination of care. The HCBS spending
plan allocates funds for residential continuum pilots
under which Medi-Cal managed care plans would pro-
vide integrated medical and supportive services in the
community. And under CalAIM, a statewide Enhanced
Care Management benefit provides high-touch care
coordination to the highest-need Medi-Cal enrollees.

If implemented as proposed, by 2023, more Medi-Cal
members will be enrolled in a managed care plan with
long-term responsibility for nursing home care and its
community-based alternatives, with the potential to
incentivize more home-based care. And in 2026, all
Medi-Cal plans may be required to offer an aligned
Medicare Advantage plan, increasing access to health
plans that manage both Medicare and Medi-Cal.
Managed care plans, especially those that integrate
benefits, have historically been more likely to offer
access to innovative home-based care models."®

Hospital at Home

For Hospital at Home services, the regulatory
landscape has evolved significantly, driven by the
COVID-19 pandemic. In March 2020, the Centers for
Medicare & Medicaid Services (CMS) announced the
Hospitals Without Walls program,"* providing broad
regulatory flexibility that allowed hospitals to provide
services in locations beyond their existing walls." In
November 2020, CMS announced the creation of the
Acute Hospital Care at Home (AHCAH) program to
help health systems and hospitals further increase care
capacity. The AHCAH program allowed for Medicare
fee-for-service reimbursement of home-based hos-
pital services. The new CMS waiver was expected to
help hospital-at-home programs thrive and spread."

The AHCAH program does not apply to longitudi-
nal care. It is for patients who require acute inpatient
admission to a hospital and require at least daily
rounding by a physician and a medical team moni-
toring their care needs on an ongoing basis. Services
could include telehealth, remote monitoring, and reg-
ular in-person visits by nurses.'?

When the CMS program was announced, it was deter-
mined that Medi-Cal would pay hospitals for acute
inpatient care for all Medi-Cal enrollees receiving care
under this waiver program. Managed care plans must
authorize and reimburse hospitals providing inpa-
tient acute care services at home through the AHCAH

 

Medi-Cal and Opportunities for Health Tech in Home-Based Medical Care

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program at the same rate they would if the services
were provided in a traditional hospital setting.

As of April 5, 2021, five health systems in California
had been approved by CMS to offer acute hospital-at-
home care under strict guidelines:"°

> Adventist Health (9 hospitals in California)
> Loma Linda University Medical Center

> Sharp Healthcare (1 hospital in California)
> UC Irvine Health

>» UC San Diego Health

"The hospital 5 to 10 years from now will be
OR, ER, and ICU. Everything else will move

into the home."
- Dan Trigub, MedArrive

Implications for Innovators

For this landscape report, interviews with a range of
stakeholders were conducted to understand their
perspectives on home-based medical care."' These
revealed that there is not widespread adoption of
home-based medical care services by Medi-Cal plans,
despite benefits to outcomes, cost, and patient satis-
faction. Forthose plans that have adopted home-based
medical care services, the initial focus was transitional
and longitudinal. Episodic care has come afterward.
As these models have been embraced, there is now
a desire for comprehensive models that encompass
transitional, longitudinal, and episodic home-based
medical care services.

Interviewees at Medi-Cal plans seeking to offer
home-based medical care services expressed a desire
to better understand the service mix, contracted
providers, and data exchange capabilities as key con-
siderations. They are also interested in providers that
have a track record of efficiency and effectiveness, and

they identified the following four points of operational
excellence they look for when evaluating potential
home-based medical care service providers.

Population Segmentation

Determining the populations to target for home-
based medical care services is challenging. It is not a
one-size-fits-all path, as home-based medical care ser-
vices are expensive interventions but can generate a
positive return on investment with the right audience.
Prior research" suggests that the following population
segments may be good fits for home-based medical
care:

> Older, homebound community-dwelling adults and
younger adults with disabilities are the prime tar-
gets for longitudinal primary care.

> Patients with multiple chronic conditions who
account for a disproportionate share of health care
spending are the primary targets for longitudinal
home-based medical comanagement and home-
based integrated medical and social care.

> Patients with serious illnesses in advanced stages
and with significant symptoms are the primary tar-
gets for longitudinal palliative care.

> Community-dwelling adults who have multiple
chronic conditions and are frequent users of avoid-
able emergency department or inpatient services
are the prime candidates for episodic community
paramedicine care. This population may or may not
be homebound.

> Hospitalized adults at risk for poor posthospitaliza-
tion outcomes are targets for transitional care, and
adults who require acute hospital admission for
certain qualifying conditions are candidates for the
Hospital at Home program.

Employing solutions that can be tailored to each
patient more effectively and efficiently can be a key
driver to the success of the home-based medical care
model.

 

California Health Care Foundation

www.chcf.org 4
Patient Engagement

Those who could benefit most from home-based
medical care services often aren't aware they exist,
and even when they are aware, many must be con-
vinced to give it a try. Once patients are enrolled in a
home-based medical care service program, there are
sometimes challenges with engagement and ensur
ing that they follow the protocols of their care plan
- including medication adherence.

There is a tremendous range of considerations with
Medi-Cal and dually eligible enrollees, including:

> Different levels of trust in the health care system.
For example, some patients have a strong relation-
ship with their existing primary care provider while
others are dissatisfied.

> Multiple languages and cultural considerations
alongside unique family and caregiving contexts.

> Social risk factors, including food and housing inse-
curity, as well as hardware, software, and broadband
digital divides.

Unlike a traditional provider setting where the patient
comes in and must conform to the provider's environ-
ment, home-based medical care presents the opposite
scenario where the primary care provider (PCP) and
care team must adapt to the patient's environment.

Caregiver Engagement

One of the key measures of a successful home-based
medical care program is patient satisfaction. These
measures extend to caregivers as well. The challenge
is that caregivers spend up to 24 hours each day with
their loved ones without a medical expert in the home,
and a fairly sizable percentage take care of relatives
with complex needs without sufficient help or training,
resulting in emotional stress.

For example, in episodic care situations, 7 of 10 family
caregivers who perform medical or nursing tasks face
the practical and emotional strain of managing pain."

This strain is magnified when caring for loved ones
with mental or behavioral challenges. After even minor
surgical procedures, it is not uncommon for patients to
experience a level of delirium. Being trained to iden-
tify, interpret, and manage these symptoms - and as
needed escalate to a clinician - could be critical to a
patient's recovery care plan.

Throughout the interviews with home-based medical
care episodic service providers, a recurring theme was
that caregiver training is an important element of the
onboarding process.

"Whether it's a family caregiver or a
professional caregiver, they have a direct

impact on patient outcomes."
- Mark Treat, Upward Health

Ability to Deliver Quality "High-
Touch" Teams at Scale

One of the success factors of the home-based medi-
cal care service model is the integration of high tech
with high-touch. A team often composed of PCPs,
specialists, registered nurses, and emergency medical
technicians all work to administer care, observe, and
make sense of the environment, coordinate with other
care providers, provide technical assistance, train care-
givers, and provide relief to socially isolated patients
and their caregivers.

The innovation challenge is how to achieve scale with
high-touch while maintaining quality and minimizing
costs. The approach can vary significantly. Home-
based medical care service providers featured in this
paper's "Solutions Landscape" offer examples:

> Contessa and Current Health leverage resources of
their client health systems and provider organiza-
tions to bring medical staff to the home.

> Current Health's tech platform integrates and man-
ages connectivity with external solution providers

 

Medi-Cal and Opportunities for Health Tech in Home-Based Medical Care

www.chcf.org 5
and provides its own 24/7 clinical command center
as nights-and-weekends backup for its provider cli-
ent teams.

>» MedArrive leverages emergency medical techni-
cians and paramedics for in-home care.

Solutions Landscape

Multiple organizations, big and small, with innovative
technologies and business models have come to the
fore. A sample of home-based medical care service
providers were interviewed for this landscape to high-
light different approaches (see Table 1). Not intended
to be exhaustive, the landscape's goal is to showcase
how different models can work within the construct of
the California health ecosystem.

The home-based medical care service providers fea-
tured in this landscape differ in their business models
and go-to-market strategies. The central tension with
each is how to maintain quality and differentiation
while scaling to meet demand.

> Primary customer. Most of the home-based medi-
cal care service providers interviewed identified the
health plan as their primary customer, while others
named health systems as the customer of focus.
Selling to plans can be challenging, at least in part
because it is difficult to identify the optimal plan
participants for home-based medical care services
without detailed cost and health information on
plan members. Working with health systems cre-
ates opportunities for home-based medical care
providers to leverage and benefit from their trust-

based brands.

> Control of wraparound service delivery. Every
home-based medical care provider
interviewed acknowledged the significance of
wraparound services as key to better outcomes with
Medicaid and Medi-Cal and dually eligible enrollees.
These services include mental health, behavioral

service

health, and social services. Landmark Health recog-
nized that community-based behavioral and social
resources are so strained that waiting periods can
sometimes stretch into weeks, so they decided to
employ a roster of psychiatrists, psychiatric nurse
practitioners, social workers, and other behavioral
and social experts to provide same-day access and
have greater control of these needed resources.
Most of the other remaining home-based medical
care service providers have some of these resources
on staff but coordinate the delivery of these services
with community agencies in a hybrid approach.

> Breadth of services provided. With one excep-
tion, all home-based medical care service providers
interviewed provided some longitudinal home-
based medical care. A few provided episodic care,
including Hospital at Home. Several started off as
with a single service and expanded into adjacent
areas to have more impact.

> Reimbursement. These pathways vary significantly
by home-based medical care service provider,
driven by the type of services offered and the popu-
lation being served. Some are in the fee-for-service
camp, others value-based, and others offer both.

Each of the featured home-based medical care ser-
vice providers claims to be unique and to have a
competitive advantage over everyone else - be it
a technology, process, or orientation to the ultimate
consumer. These differentiators have been highlighted
to illustrate the innovation pathways being pursued in
this rapidly growing industry.

 

California Health Care Foundation

www.chcf.org 6
Table 1. Home-Based Medical Care Service Providers

Underrepresented Founders/CEO*

 

 

LONGITUDINAL AND CALIFORNIA
EPISODIC SERVICES PAYMENT MODELS DIFFERENTIATION FOOTPRINT
Longitudinal > Value based - Go to market via joint Yes
(+ CONTESSA >» Medical comanagement MCOs venture partnerships ve ~m
. ith hospitals; leverage >PI"t
> Palliative care » Shared savings \. it er vereg
with providers ospital resources.
> Primary care
> Medicare FFS
Episodic
> Hospital at home
> Transitional
Longitudinal > Value based - Health system is Contracted
Q¢9 current health 7 Ones
'ABest Buy Health" Company > Complex chronic condition total cost of care, primary customer; in California
management global budget, very rich connectivity in multiple
> Medical t episode bundles into the home. Other communities
eacal comanagemen devices and vendors (services

> Integrated medical and
social

> Palliative care
Episodic

> Acute in-home

> Hospital at home

> Transitional

> CMS AHCAH waiver
(DRG)

> Commercial,
Medicare,
Medicaid FFS

can seamlessly connect
to technical platform.

Smartphone or internet
connection not needed.

commence 2022)

 

 

 

dispatchhealth Episodic Value based - Consumer-driven Yes
> Community paramedicine / discounted on-demand "ER in
acute in-home bundled rates home."
> Hospital at home Customers are both
, health plans and health
> Transitional
systems.
@ Land k Longitudinal Value based - Predictive modeling / Yes
anamear > Integrated medical and shared savings with real-time action-
social health plans or take able data to send
full risk the highest-acuit
> Medical comanagement wens Signe een y
resources to the "most
> Palliative care likely" sickest patients
oy. and those with increas-
Episodic a :
ing risk velocity.
> Community paramedicine /
acute in-home
> Transitional
Longitudinal FFS Turnkey access to broad Yes

W Med Arrive

> Medical comanagement

Episodic
> Community paramedicine /
acute in-home

> Transitional

network of EMTs and
paramedics to extend
care into the home
under the oversight of
telemedicine-based
physicians.

(2021 entry)

 

* The California Health Care Foundation (CHCF) is committed to promoting diversity, equity, and inclusion through its program-related investments, grantmaking,
culture, and organizational operations. CHCF supports people from diverse and historically underrepresented backgrounds because such efforts are essential to
building an inclusive, innovative, and sustainable health care ecosystem. With that in mind, all the home-based medical care service providers interviewed were
asked to identify whether they were founded or are being led today by those with historically underrepresented backgrounds. Some companies did not respond.
Table 1. Home-Based Medical Care Service Providers, continued

Underrepresented Founders/CEO*

 

MED@ZED

LONGITUDINAL AND CALIFORNIA
EPISODIC SERVICES PAYMENT MODELS DIFFERENTIATION FOOTPRINT
Longitudinal Value based - Continuity of virtual Yes

> Integrated medical
and social

» Palliative care
» Primary care
Episodic

> Transitional

capitation and
shared savings

(6 managed care
contracts)

PCP and in-person
nurse - key to build-
ing trust and providing
better outcomes.
Seamless telemedicine
model.

 

M@BILE PHYSI@IAN

Longitudinal
» Primary care

Medicare FFS

Complete group mobile Yes
medical practice. PCPs
are consistently on the

 

 

Associates road. Proprietary "Uber
for doctors" platform
geo-maps PCPs to
in-need patients in
real time.
"™ Longitudinal > FFS Truly integrated Yes
lal > Integrated medical > Value based whole-person model. va Mae of
. : we t
Upward ealth and social Physical medicine, an Mateo.
behavioral health, and
» Medical comanagement . .
social determinants
> Palliative care of health all treated
> Primary care equally.
Episodic
> Community paramedicine /
acute in-home
> Hospital at home "light"
> Transitional
healthcare Longitudinal > Value based - Integrative model but _In process
Vesta > Integrated medical full population very caregiver-centric. | of entering
and social level risk California

» Medical comanagement

» Medicare FFS

 

Notes: MCO is managed care organization. FFS is fee-for-service. CMS is Centers for Medicare & Medicaid Services. AHCAH is Acute Hospital Care at Home. DRG is
diagnosis related group. EMT is emergency medical technician. PCP is primary care provider.

 

California Health Care Foundation

www.chcf.org 8
Key Takeaways Plans and Systems

When seeking a partner for delivery of home-based

Innovators

medical care, it is important to:

To succeed in Medi-Cal, it is important to: > Be clear on your goals and the problem(s) you are

> Identify your customer in Medi-Cal's fragmented
system - a health plan, delegated medical group,
or health system.

> Match the service mix and model of care, and
reimbursement model, to the specific pain points
expressed by the customer, acknowledging both the
need for holistic, whole-person care and California's

trying to solve. Your population's needs and the
gaps in your network can help determine whether
you are trying to improve access to comprehensive
primary care for people who are home-bound, to
provide enrollees with an alternative to the emer-
gency room, or to offer hospital-level care in a
home setting due to limited hospital capacity.

. . > Identify your target population and ensure the pro-
carve-out from Medicaid managed care of specialty . ity y ger POP . P .
vider's care team and staffing model meet their
mental health and substance use treatment as well i .
. . needs. Also, be realistic about who will be engaged.
as many home and community-based services. . .
Some enrollees may be challenging to reach, while
> Be prepared to provide care that is culturally spe- others may strongly prefer to stay with their existing
cific and culturally attuned to address significant care team. All these factors can impact the actual
diversity in languages and cultures. The ability uptake and efficacy of the intervention.
to provide culturally responsive care presents an . . .
P . rey P oe P > Consider approaches that include reactive work-
opportunity to improve equity in outcomes that can . .
. . . flows to connect enrollees with home-based medical
only be realized with excellent execution. . .
care (e.g., upon hospital discharge or referral from
> Interface with and acknowledge existing provider care coordination) and proactive population health
networks and be thoughtful about data exchange workflows (e.g., those that use claims data to iden-
to reduce the barriers to coordinated care. tify enrollees that would benefit). Both approaches
. . can optimize the reach of the intervention.
> Pay attention to, and move swiftly, to take advan-
tage of the favorable payment and regulatory > Recognize that these models are often more expen-

tailwinds in California.

sive than traditional care settings at a unit cost level
and identify a contracting approach that meets both
the needs of the plan and the home-based medical
care provider. The arrangements may change over
time as more information is gathered about uptake,
efficacy, quality, and return on investment.

 

Medi-Cal and Opportunities for Health Tech in Home-Based Medical Care

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Innovation in Action: Programs of All-inclusive Care for the Elderly

The PACE model" is centered on the belief that it is better for the well-being of seniors with chronic care needs and
their families to be served in the community whenever possible, and that by meeting social needs, medical costs are
avoided. It is a value-based reimbursement program that delivers fully integrated social and medical care throughout
the country, including California. While there is evidence that this model works and creates value for all stakeholders,
scalability is a challenge.

California has 20 PACE providers serving patients age 55 or older, deemed eligible by the state to receive nursing
home-level care, able to live safely in their community at the time of enrollment, and living in a PACE service area. As
of March 1, 2021, over 12,000 participants are enrolled in California:

> Average age is 76, with 33% over age 80.
> Participants have strong racial/ethnic diversity.

> Average 20 medical conditions; 64% have 3+ limitations in daily living activities, and 33% have Alzheimer's
or related dementia.

> 100% of enrollees are eligible for Medi-Cal, with 75% dually eligible for Medicare and Medi-Cal and
25% Medi-Cal eligible only.

PACE provides active delivery of preventive care, wraparound social support, and regular access to physicians and
other health care professionals predominantly in a center-based model. Services include primary and specialty medi-
cal care, adult day care, in-home services, home care, prescription drugs, laboratory and diagnostic services, physical
and occupational therapies, meals, transportation, and as necessary, hospital and nursing home care. An interdisciplin-
ary team of physicians, nurses, social workers, therapists, and aides develops each treatment plan and manages all
services.

There is evidence that the PACE program delivers value:

> PACE capitation rates are set below the level the state would pay for a comparable population outside of PACE -
on average 40% less than the cost of institutional care for a dually eligible enrollee and 42% less for a Medi-Cal
enrollee.
In 2021, CalPACE (the association for California PACE programs) estimated that California will pay $130.8 million
less than it would have if all current PACE participants were served outside of PACE.

> CalPACE identifies fewer hospitalizations, fewer nursing home admissions, an increased number of days in the
community, better health, better quality of life, greater satisfaction with overall care arrangements, and better
functional status as the key sources of value for its participants. Program data as of July 1, 2020, show that 92% of
enrollees were very satisfied with their overall care in PACE, and 92% would refer PACE to a close friend. Ninety-
seven percent of caregivers would also recommend PACE.

Note: To find Program of All-inclusive Care for the Elderly (PACE) in your community, enter your zip code below the
map on the CalPACE website.

 

 

 

 

California Health Care Foundation www.chcf.org

10
 

 

Innovation in Action: Health Plan of San Mateo

"In the marketplace, most models have been traditionally one or the other, longitudinal in nature or episodic in
nature. But the tides are changing. Most plans now need a hybrid model where both services are available to them,

and the marketplace needs to pivot to that."
- Amy Scribner, Health Plan of San Mateo

Health Plan of San Mateo (HPSM) is a local community-based health plan with a vision that "healthy is for everyone."*>
Created in 1987, their programs today cover more than 130,000 people in San Mateo County - roughly one in five
residents. In addition to Medi-Cal, they also offer a plan for dually eligible enrollees.

While home-based medical care services are primarily targeted toward their dually eligible population, HPSM offers a
way for non-dually eligible Medi-Cal members to be referred in. HPSM started out with longitudinal care because of
the volume of members who needed it, and eventually expanded the model to episodic care based on growing needs
for stabilization in communities for members three to six months after an acute event.

Some clear benefits realized by HPSM from home-based medical care services include:
> Improvement in readmission rate from both longitudinal and episodic models.

> Rapid and holistic follow-up following an acute stay: It is often challenging to get patients into a follow-up
medical appointment after a hospitalization or skilled nursing facility stay. With home-based medical care, this
has improved, and home-based medical care providers can write orders and seek authorization for durable
medical equipment and other needed services after acute events while surveying the home environment -
something community-based providers in a clinic may not be able to do.

> Integration of behavioral and social wraparound services, as medical models alone tend to be insufficient for
dually eligible and Medi-Cal populations.

> Better understanding the population and their needs through physical presence in homes.

> Improvement in completion of coding of diagnoses, critical for risk adjustment.

Challenges include:
> Determining the right "graduation point" model for enrolling patients. It's not a one-size-fits-all population
approach. Some patients have a positive relationship with their PCP in their community, and home-based
medical care may not add much value for them. Their solution came in 2020 with the implementation of Alert
Care, a joint endeavor whereby patients were able to have an annual visit with their PCP and home-based medical
care service provider, and then have access to urgent care home-based medical care services as needed through-
out the year. It was hugely successful and very well received.

> Consistently realizing outcomes beyond readmission rates (e.g., cost containment, HEDIS measures, member/
caregiver satisfaction scores).

> Navigating complex payment models. HPSM eventually evolved to a quality and outcomes incentive-based
program as a preferred payment structure (per-member per-month).

> Seamlessly integrating the systems of HPSM with the home-based medical care service provider so that data
captured by the home-based medical care service provider - claims, utilization, encounters, care plans, and
medical records - could be readily available by HPSM.

Health Plan of San Mateo began their home-based medical care program in 2016, working with Landmark Health
(featured in this report). In late 2021, Upward Health (also featured in this report) was selected as the new home-based
medical care service provider for HPSM.

 

 

 

Medi-Cal and Opportunities for Health Tech in Home-Based Medical Care www.chcf.org 11
About the Author

Value Exchange Catalysts is an independent consult-
ing company with expertise in strategy, innovation,
and optimization of stakeholder value in complex rela-
tionships. Principal Nigel Smith, MBA, is responsible
for project management and execution. Nigel was
formerly the director of Innovation Labs at AARP, and
is currently also CEO of Zurena, a beverage start-up,
and board member of TATIL and Tatil Life insurance
companies.

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.

About the Innovation Landscape Series

As part of its efforts to help promising products and
services succeed and scale among California's safety-
net providers, the CHCF Innovation Fund conducts
high-level landscape analyses of issue areas especially
ripe for tech-enabled innovation. The Innovation Fund
publicizes the findings of these landscape analyses to
inform other funders and customers seeking scalable
solutions to challenges faced by safety-net providers.

Readers should note that these reports are not intend-
ed to be exhaustive, nor are they endorsements of the
companies included in them. Finally, because solutions
landscapes can evolve quickly, these reports may not
fully reflect the current market.

www.chcf.org/innovationfund

 

 

California Health Care Foundation

www.chcf.org

12
Endnotes

1.

21.

5. Christine Ritchie et al., Medical Care at Home Comes of Age,

California Health Care Foundation (CHCF), January 2021.

6. Medical Care, CHCF.

7. Managed Care Performance Monitoring Dashboard Report 22.
(PDF), California Dept. of Health Care Services (DHCS), January 9, 23.
2020.

8. Harlan M. Krumholz, "Post-Hospital Syndrome - an Acquired, 24.
Transient Condition of Generalized Risk," New England Journal 25

10.

11.

12.

13.

14.

15.

16.

17.

. William Erickson, Camille Lee, and Sarah von Schrader, 2018

. Hans Johnson and Laurel Beck, Planning for California's

Mattan Schuchman, Mindy Fain, and Thomas Cornwell, "The
Resurgence of Home-Based Primary Care Models in the United
States," Geriatrics (Basel) 3, no. 3 July 16, 2018): 41.

Disability Status Report: California (PDF), Cornell Univ., 2020.

Growing Senior Population, Public Policy Institute of California,
August 2015.

of Medicine 368, no. 2 (Jan. 10, 2013): 100-2.

. Medicare-Medicaid Linked Enrollee Analytic Data Source

(MMLEADS) Public Use File (PUF) Version 2.0 (2006-2012),
Centers for Medicare & Medicaid Services (CMS), February 2019.

Melony E. Sorbero et al., Types and Costs of Services for
Dual Beneficiaries by Medicare Advantage Health Plans: An
Environmental Scan, RAND Corp., 2018.

Addressing Social Determinants of Health Through Dual-
Eligible Special Needs Plans: Gap Analysis and Policy
Development, Center for Health Care Strategies, October 2020.

"Report to Congress: Social Risk Factors and Performance
Under Medicare's Value-Based Payment Programs," US

Dept. of Health and Human Services, December 20, 2016; and
Accounting for Social Risk Factors in Medicare Payment
Programs: Identifying Social Risk Factors, Nat'l Academies of
Sciences, Engineering, and Medicine, 2016.

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.

Jacey Cooper (state Medicaid dir, DHCS), "Implementation of
the American Rescue Plan Act (ARPA) of 2021 Section 9817:
Additional Support for Medicaid Home and Community-Based
Services (HCBS) During the COVID-19 Emergency" (PDF),
September 17, 2021; and California Advancing & Innovating
Medi-Cal (CalAIM) Proposal (PDF), DHCS, January 2021.

Giselle Torralba et al., Meeting the Moment: Strengthening
Managed Care's Capacity to Serve California's Seniors and
Persons with Disabilities, CHCF, April 2021.

"Additional Background: Sweeping Regulatory Changes
to Help U.S. Healthcare System Address COVID-19 Patient
Surge," CMS, March 30, 2020.

CMS, "CMS Announces Comprehensive Strategy to Enhance
Hospital Capacity Amid COVID-19 Surge," press release,
November 25, 2020.

20.

. Christopher Cheney, "CMS Home-Based Hospital Care Waiver

wa

Called 'Enormous Step Forward,
2021.

HealthLeaders, January 6,

. "The Acute Hospital Care at Home Program," DHCS, last

modified January 24, 2022.

"Acute Hospital Care at Home Program: Approved List of
Hospitals as of 4/5/2021" (PDF), CMS.

Organizations interviewed include Center for Elders'
Independence PACE, CommonSpirit Health, Family Caregiver
Alliance, Front Porch, Health Plan of San Mateo, Justice in Aging,
LifeLong Medical Care, and SCAN Health Plan.

Medical Care, CHCF.

Susan C. Reinhard et al., "Home Alone Revisited: Family
Caregivers Providing Complex Care," AARP, April 2019.

CalPACE.

. Health Plan of San Mateo.

 

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