Slide 1: Center for Consumer Engagement - in health innovation
Justice in Aging - fighting senior poverty through law
Leena Sharma
Project Manager & Senior Policy Analyst
Center for Consumer Engagement in Health Innovation
Community Catalyst
Amber Christ
Directing Attorney, Health Care 
Justice in Aging

One Care Implementation Council Meeting
May 12, 2020

Slide 2: Center for Consumer Engagement in Health Innovation
The Center’s mission is to bring the consumer experience to the forefront of health innovation in order to deliver better care, better value and better health for every community, particularly vulnerable and historically underserved populations.
Justice in Aging
Justice in Aging is a national organization that uses the power of law to fight senior poverty by securing access to affordable health care, economic security, and the courts for older adults with limited resources. Since 1972 we’ve focused our efforts primarily on fighting for people who have been marginalized and excluded from justice, such as women, people of color, LGBTQ individuals, and people with limited English proficiency.
Slide 3: The Promise of Coordinated Care
Note: 
This slide includes a graphic showing the Promise of Coordinated Care. The graphic includes five circles – Member, Medical, Social, LTSS and Behavioral. The Member circle is in the center surrounded by four other circles - Medical, Social, LTSS and Behavioral. There is a line between the member circle and each outer circle illustrating the connection between them.
Slide 4: The Promise of Coordinated Care: Care Team
Note: 
This slide includes a graphic showing the Promise of Coordinated Care: Care Team. The graphic includes five circles – Member, Care Coordinator, LTS Coordinator, Primary Care and Specialists. The Member circle is in the center surrounded by the four other circles - Care Coordinator, LTS Coordinator, Primary Care and Specialists. There is a line between the member circle and each outer circle illustrating the connection from one to the other.
Slide 5: Care Coordination in the Duals Demos: What do we know from RTI evaluations?
•	High beneficiary satisfaction with the demonstrations, yet care coordination function did not live up to the expectations.
•	Health risk assessments were challenging to complete, especially for hard to reach populations
•	Plans reported that they provided documented care coordination plans for 50 percent to 60 percent of members. 
•	Though members were often unaware of these care coordination services. In half of all plans, fewer than 30 percent of members reported receiving assistance with care coordination.
•	Turn over was also an issue among care coordinators (17% in Ohio and 22% in Illinois by the second demonstration year)
Slide 6: Integrated Care in the Era of COVID-19
How do we enhance the care coordination function, especially during current crisis, given what we know from the evaluations of the duals demonstrations?
Slide 7: Key Elements for Care Coordination during COVID-19

Care planning
•	Articulation of Goals 
•	Medication and Supplies
•	Social Determinants of Health 
•	Contact Information 
•	Review
Care Coordination
•	Triage
•	Review and Update Care Plan 
•	Screening
•	Caregiver support
•	Congregate Settings
•	Other Considerations
Data Collection
•	Intersectional data
•	Public reporting
Slide 8: Care Planning
•	Articulation of Goals 
o	Led by Member using member’s own words and language
o	Organized by topic: health care; behavioral health; social needs
o	Language preference/preferred means of being contacted 
•	Medication and Supplies
o	List of meds
o	Durable Medical Equipment 
o	Other supplies 
•	Social Determinants of Health 
o	Physical Living Situation 
o	Social Living Situation 
o	Personal Care Attendant and other supports 
•	Contact Information 
o	Care Coordinator; LTS Coordinator; Other Members of ICT
o	Personal Care Attendant 
•	Review
o	Review with member on regular basis with member
o	Triggering Events (e.g. COVID)

Slide 9: Care Coordination

•	Triage, but goal to reach every member
•	Review and Update Care Plan 
•	Screen for: 
o	Upcoming appointments; rescheduling; securing transportation 
o	Unmet needs (DME; medical; mental health; interpreter services; medication refills, etc.) 
o	Caregiver availability; access to PPE 
o	Need for being tested; connecting to testing  
o	Ability to receive care through telehealth; connecting to devices needed
o	Food Security 
o	Social Isolation 
o	Education on changes to health plan is approving services; social distancing; 
o	Eligibility Issues; housing; other benefits 
o	Emergency contact
Slide 10: Care Coordination
•	Caregiver support
o	Education 
o	Respite 
o	PPE; testing 
•	Congregate Settings
o	Partnering with long-term care ombudsman
o	Ensuring virtual visits 
•	Other Considerations
o	24 hour nurse hotline
o	Online access
o	Education line 
Slide 11: Data Collection
•	Need for intersectional data
o	Race
o	Age
o	Sex
o	Language
o	Disability
o	Setting (home; residential care; institutional)
•	 Importance of uniformly collecting and publically reporting data
Slide 12: Questions?
Leena Sharma
lsharma@communitycatalyst.org
Amber Christ
achrist@justiceinaging.org