Title Slide: CCA’s SDOH Response During COVID-19

Presentation to One Care Implementation Council 
July 14, 2020
Note: footer on each slide includes the Commonwealth Care Alliance logo
Slide 1: Member Engagement During COVID-19
•	CCA’s top priority during COVID-19 has been member engagement
•	CCA care teams have provided individualized communication addressing specific concerns of each member, including:
o	Over 260,000 virtual engagement activities
o	Over 47,000 COVID-19 screenings
o	Over 24,000 billable telehealth visits
o	Over 27,000 members engaged via wellness outreaches
•	CCA is expanding our deployment of LifePod® remote patient monitoring devices to enable care teams to check in with members and address social isolation, provide medication reminders, and educate members about how to protect themselves from and identify symptoms of COVID-19
Slide 2: Health Outreach Workers (HOWs) Focused on SDOH
•	CCA health outreach workers, with deep understanding of the local community and ability to relate with members, are focal points on the care team and partner with members on addressing social determinants of health
•	During COVID-19, HOWs have increased access to SDOH support for members, including through new HOW roles such as: 
o	Resource Specialist Health Outreach Workers (RS-HOWs) are responsible for compiling a resource guide – through daily telephonic outreach to community organizations – with the aim of having the most up-to-date SDOH resources members can access
o	HOW of the Day team members are available to respond to any request for members with urgent SDOH needs; CCA provides weekly calendars to connect clinicians in the field with this specialized team
Slide 3: Addressing Food Insecurity During COVID-19 
•	CCA has relaxed the criteria for home delivered meals, extending the service available to a growing number of members who are faced with food insecurity challenges during COVID-19
•	CCA launched the Member Support Program to help CCA members cover the costs of needs, including food and health and wellness items
•	The HOW-created resource guide includes community-based formal and informal food supports, such as food pantries, brown bag lunches, grocery and meal delivery, and mobile food banks, as well as operating information, senior hours, and state and federal updates to benefits like SNAP
•	CCA has allowed caretakers and family members to travel using the transportation benefit to obtain food, medications, and basic necessities
Slide 4: Addressing Homelessness During COVID-19

•	CCA has dedicated a specialized HOW team to help homeless and housing insecure members find housing and reduce the risk of transferring COVID-19 among homeless populations
•	The HOW-created resource guide includes housing resources for homeless and housing insecure members at-risk or positive for COVID-19
•	Approximately 500 CCA members have received some type of housing assistance from our HOWs, like housing application assistance, rental assistance resources, housing education, and other housing support
•	Managing Isolation & Recovery Sites, in collaboration with the Commonwealth’s COVID-19 Command Center and MEMA, CCA has served nearly 500 COVID-positive individuals in need of a safe place to isolate, including some CCA members
Slide 5: Appendix
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Slide 6: Alternative HCBS to Reduce Risk of Hospitalizations
•	In early March, CCA identified members at high risk for a poor outcome should they be infected with COVID-19; these members have one or more key conditions, such as chronic obstructive pulmonary disease, diabetes, frailty, homebound, respiratory-dependent, among other chronic conditions
•	To help monitor symptoms and risk factors, CCA leverages Google Cloud Looker which aggregates the most up-to-date data into one easy-to-use view
•	CCA has proactively outreached and visited members at highest risk for hospitalization, with the goal of keeping them safely in the community and avoiding an unnecessary hospitalization 
•	CCA integrates DPH city infection rates with the addresses of our high-risk members to identify hot spot areas of our membership and inform member engagement around preventative and social distancing guidelines
Slide 7: Alternative HCBS to Reduce Risk of Hospitalizations 
•	Through close collaboration with Independent Living Centers and Aging Services Access Points, CCA’s internal LTSS response workgroup adapted a best practice LTSS Priority Ratings tool to identify high-risk members based on medical complexity, functional ability, and informal supports that can assist during the emergency
•	We are identifying members at highest risk of losing LTSS access, like personal care attendant (PCA) services, and would have potential for adverse outcomes as result
•	Care partners, Long-Term Supports Coordinators, and Geriatric Services Support Coordinators received special training and are updating each member’s LTSS priority rating through knowledge of member needs and wellness checks
Slide 8: Nutritionally Tailored Meals
•	CCA collaborated with Massachusetts General Hospital and the AARP Foundation to create a pilot in which a select group of CCA members received medically-tailored meals from our partner Community Servings
•	The pilot created two groups of members in which CCA paid for meals tailored for those with chronic conditions like diabetes, HIV/AIDS, cancer, heart disease, kidney disease, and other life-threatening illnesses, and a second group of members received non-tailored meals
•	Participants in both meal programs experienced fewer ED visits and emergency transportation services than in the control groups; only medically-tailored meal participants had fewer inpatient admissions, with a 16 percent net reduction in health care costs
•	Through COVID-19, our partnership with Community Servings to provide nutritionally tailored meals has continued
Slide 9: Risk Mitigation of COVID-19 Transmission
•	Since mid-March, CCA has approved personal care equipment consistent with CDC guidance for scrupulous hygiene and infectious control measures
•	CCA has removed restrictions for authorizations for equipment, including gloves, hand sanitizer, soap, sanitizer wipes, and masks
•	In the event that a PCA needs to care for a quarantined member, CCA will cover PCA equipment, including goggles, masks, gloves and gowns, although we recognize the challenges associated with the supply chain
Slide 10: Outreach to Other Specific Groups of Members
•	Members at high-risk for behavioral health crisis or overdose are receiving close and consistent virtual contact by our addiction specialists and behavioral health specialists
•	Over 460 other referrals for SDOH assistance were successfully addressed with our members for needs such as phone assistance, cultural and linguistic support, provider engagement, medical forms, and applications