Medicare MCOs reach out to Alzheimer's patients
Patients stay home, caregivers stay healthy
Alzheimer's disease costs an estimated $1 billion annually, placing it just behind heart disease and cancer in the strain it puts on the health care delivery system, according to the Alzheimer's Association in Chicago. Concerned with the growing cost of caring for Americans with adult demen tia, managed care plans are reaching into the community for partners to help them deliver services to this population, estimated to reach 14 million by the middle of the 21st century.
There are several obstacles to providing appropriate care for adults with dementia that Medicare risk plans hope alliances with community agencies will help them overcome, say experts interviewed by Physician's Managed Care Report. Those obstacles include the following:
· difficulty securing reimbursement for individuals who need ongoing custodial care;
· inadequately trained providers, especially in the area of dementia care;
· lack of a coordinated service delivery system.
The Alzheimer's Association recently awarded grants to about 20 Medicare risk plans to develop managed care models that include alliances with community resources, such as local chapters of the association. "There's no data that says what works and what doesn't work when it comes to managed care for Alzheimer's patients," says Katie Maslow, MSW, director of the Initiative on Alzheimer's and Managed Care for the Alzheimer's Association. "The purpose of the projects is to figure out what really can be done in Medicare managed care for adults with dementia."
Who's in charge here?
Issues the association hopes the demonstration projects will clarify include the following:
· How should case managers inside Medicare risk plans and in the community interact?
· Are the goals of case managers inside Medi care risk plans the same as those of community-based case managers?
· Is the focus of case managers in managed care limited to management of medical services covered by the plan?
· Is there an unnecessary duplication of efforts between case managers in Medicare risk plans and their peers in the community?
"Frail elders with dementia tend to have multiple case managers," Maslow says. "There is no one with clear authority, and it's often confusing for the family."
The question of the appropriate case management model for the Alzheimer's population is not the only issue the demonstration sites hope to explore. Managed care plans have several obstacles to overcome before they can provide appropriate care for adults with dementia, says Nancy V. Leonard, MSW, LCSW, social services care manager for Connecticut Community Care in Bristol. Leonard provides care management services for Anthem Blue Cross and Blue Shield of Connecticut in New Haven in one of the recently launched demonstration projects.
To succeed in providing appropriate, cost-effective care for Alzheimer's patients and other frail elders, Leonard recommends that Medicare managed care models include these items:
· Recognition that older adults and their informal support networks of family and friends are the central focus of the care plan.
· Provision of services that meet the needs of frail elders. "High-tech interventions respond to the needs of some populations, but services for elders must include low-tech services such as homemaker, companion, and home-delivered meals," she notes.
· Use of a comprehensive care management model to identify the unique strengths and deficits in each client's situation and to maximize available community resources.
· Provision of appropriate access to specialty care when necessary. "In view of the increasing number of Alzheimer's patients and older adults with other related disorders, it's important that the services of geriatricians, geriatric psychiatrists, neurologists, nurses, and social workers be available to address the needs of elders and their families," Leonard says.
· Provision of respite care services for informal care providers. "A full 80% of all care to frail elders is provided by their informal care systems, such as spouses, children, grandchildren, as well as friends," she says. "Without respite care, informal caregivers are unable to continue their vital role in the long-term care system."
· Recognition of the desire of the elderly to remain in the community. "Managed care models must provide a full range of community care services in their benefit plans designed to help keep the elderly in their own homes whenever possible," she says.
One of the biggest obstacles Medicare managed care plans face is not in delivering appropriate services, but in identifying those in need of the services, adds Julie M. Gelgauda, MS, LCSW, health and wellness advisor for Anthem Blue Cross and Blue Shield. "One service we offer is respite care. We had members calling and asking for the respite benefit, but we were concerned about members who might not yet have taken advantage of the benefit. How could we reach them earlier? How could we offer caregivers care management services and education?"
Identifying Alzheimer's patients and their caregivers early in the disease process has clear advantages for Medicare managed care plans, she notes. "First, there are drugs and other interventions that can slow the progression of the disease, if interventions are started sooner. Second, a lot of times caregivers are members, too. By intervening earlier with respite care and other services, we keep caregivers' stress down, and they remain healthier."
Elizabeth Baxter, coordinator of the Chronic Care Initiative for Legacy Health System in Port land, OR, agrees: "If we find Alzheimer's patients earlier in their disease process and train caregivers before they reach burnout, we can save the health plan money." Her organization is a relative newcomer to the Medicare managed care arena, whose demonstration project partner is the Oregon Trail Chapter of the Alzheimer's Association.
"Our challenge is that dementia is not the primary diagnosis for 99% of primary care patients," she points out. "Patients come in because they've fallen or they're depressed. Dementia may not even be coded for, or it may be the second or third diagnosis."
Anthem Blue Cross and Blue Shield routinely completes health risk appraisals on all members. For this project, members who report changes in thinking ability, memory, or at least one activity of daily living (ADL) or instrumental ADL are contacted by staff trained to ask questions designed to identify members experiencing cognitive changes. Originally, Gelgauda says Anthem focused on members who reported losses in thinking ability or memory, but later it found that adding reported change in at least one instrumental ADL or ADL helped with selection in the screening process. "Things like problems with money management or shopping can be very telling," she says.
The phone interviewers are trained not to launch into questions about losses, Gelgauda says. "Most of these patients have comorbidities that offer an opportunity to initiate discussion, as well as reveal potential problems. For example, the interviewer might say, 'You report that you have diabetes. How do you think you are managing that?' Our clinical nurse suggested that during the telephonic screening, if we identify that there appears to be a cognitive change, we utilize additional questions from the FAST assessment instrument.1 This assists us in gaining a better idea of areas of challenge for the member."
If phone assessment uncovers or confirms areas of concern, the member is offered a visit from the care manager to discuss them. "Most members were thrilled to have [the care manager] come out. We give the referral to her, and she would go to the home to complete a comprehensive assessment."
Legacy also assigns staff to call members who report memory loss or cognitive impairment on a health risk appraisal sent to all its Medicare managed care members. "We've found one of the most predictive items for Alzheimer's is if the questionnaire was completed by a proxy," Baxter notes.
Legacy and Anthem Blue Cross and Blue Shield have used trainers from local chapters of the Alzheimer's Association to educate caregivers, providers, and their own staff about the needs of Alzheimer's patients and families. Anthem even asked trainers from the North Central Chapter of the Alzheimer's Association in Hartford, CT, to provide inservices for its member representatives. "The member reps said the inservice was directly applicable to their daily work," Gelgauda says.
It took a mishap to prompt Legacy reach out and train all service providers who come into contact with its Alzheimer's population, Baxter recalls. "We used cab drivers to transport patients to and from adult day care. One day, a midstage Alzheimer's patient who was still very articulate convinced a cab driver to let him out at a department store they passed on the route home. Two hours later, his daughter called us very frantic because her father had not returned home."
The Oregon Trail Chapter provided an inservice for the cab drivers to give them the skills necessary to know how to respond to those types of situations. "The same cab company often drives children with mental disabilities for the school district. They responded very well to our request that they come in for training," says Baxter.
Reference
1. Reiberg B, Ferris S, Franssen E. Practical geriatrics: An ordinal functional assessment tool for Alzheimer's type dementia. Hosp Comm Psych 1985; 36:593-595.
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