A New Care Paradigm Slashes Hospital Use and Nursing Home Stays for the Elderly and the Physically and Mentally Disabled

Meyer H
Source: Health Affairs
Publication Year: 2011
Patient Need Addressed: Care Coordination/Management, Chronic Conditions, Patient satisfaction/engagement
Population Focus: Dual eligible, Medicaid eligible, Vulnerable/disadvantaged
Demographic Group: Adult
Intervention Type: Best practices, Service redesign, Staff design and care management
Type of Literature: White

SYSTEM: Commonwealth Care Alliance, a not-for-profit healthcare system based in Boston, Massachusetts, offering a full spectrum of medical and social services for older people and the physically and mentally disabled.
Key Innovation: Providing individualized primary care, coordination, behavioral health, and social support services in the home and community through multidisciplinary teams, thus reducing the need for hospitalization and nursing home placement for the elderly and disabled.

COST SAVINGS: Sharply reduced use of nursing homes by eligible older people led to an average growth in total medical spending of just 2.1 % from 2004 to 2009, sharply below fee-for-service rates. For disabled patients, monthly medical costs were $3,601 in 2008, compared to $5,210 for Medicaid fee-for-service patients.


RESULTS: In 2009 Commonwealth Care Alliance scored in the ninetieth percentile or above on Healthcare Effectiveness Data and Information Set measures for comprehensive diabetes care, monitoring patients on long-term medication, and access to preventive services.

CHALLENGES: The alliance seeks integrated global payments with appropriate risk adjustment from multiple payers; needs to build adequate financial reserves to satisfy insurance regulators; has to shore up struggling primary care physician practices to serve as a foundation for its programs; and struggles to recruit a multilingual, multidisciplinary workforce to serve a multilingual population.

Insights Results

Overview of article/program

  • This article provides an overview of programs developed by the Commonwealth Care Alliance that target older people and the physically and mentally disabled
  • The Commonwealth Care Alliance launched different programs, such as the Senior Care Options and Disability Care Program, that focus on identifying patient needs to provide a rich array of services that are best for individual patients. Both programs have reduced hospitalizations and nursing home placements and have curbed total medical spending growth
  • In early 2010, Commonwealth Care Alliance launched the Complex Care Needs program to serve Medicaid-eligible adults and children with multiple chronic illnesses. This program uses a multidisciplinary approach to primary care and relies on community health workers to keep patients engaged in their treatment
  • Patients voluntarily join Senior Care Options through referral from one of the participating primary care practices or from outside sources. Services are provided through multidisciplinary teams, including community health workers, and behavioral health, physical therapy and palliative care clinicians. Both programs partner with Medicare, Medicaid and health systems to provide home- and system-based services
  • The plan receives capitated payments from Medicare and Medicaid and delivers services through its own facilities and affiliated provider groups, which it pays in turn either on a full or modified capitation basis. These providers include group practices, federally qualified community health centers, academic practices, and an independent practice association. Commonwealth Care Alliance provides “wraparound” clinical and support staff to its primary care sites
  • The process starts with a comprehensive patient assessment of medical, social, behavioral, and support needs, conducted at home for homebound patients. The nurse practitioner and others on the team have broad leeway to order services, without prior approval from the plan. Patients can access clinical help around the clock. All staff members, including telephone support staff, have 24/7 access to the patients’ electronic health records
  • Commonwealth Care Alliance and an affiliated nonprofit, Boston’s Community Medical Group, also provide comprehensive care through the Disability Care Program to about 400 mostly nonelderly adults in eastern Massachusetts. These patients have severe physical disabilities
  • The Disability Care Program has risk-adjusted capitated contracts with Medicaid and the Neighborhood Health Plan. This one uses multidisciplinary teams of physicians, nurse practitioners, and others. The teams provide assessments; care planning; 24/7 staff availability; and intensive medical, behavioral health, palliative care, and social support services in the home and community. Once again, the goal is to maintain patients’ health and keep them out of hospitals and institutions. The program has contracts with a preferred network of medical specialists and vendors experienced in serving disabled people
  • In early 2010 Commonwealth Care Alliance, collaborating with the Cambridge Health Alliance and Network Health, launched the Complex Care Needs program to serve Medicaid-eligible adults and children with multiple chronic illnesses, many with mental health and substance abuse needs. The program currently serves 1,900 adults and 500 children through 10 primary care sites, using a multidisciplinary primary care model similar to the other two programs. It also relies on community health workers to keep patients engaged in their treatment


    • Unpublished data for Senior Care Options in 2007 show that the number of hospital days per 1,000 members was equal to just 55% of hospital days for comparable dual eligibles cared for in a fee-for-service payment environment
    • An external survey found high member satisfaction in the Senior Care Options program
    • For Disability Care Program patients, unpublished data show that total monthly costs were $3,601 in 2008, compared with $5,210 for Medicaid fee-for-service patients with conditions of similar severity

    Key takeaways/implications

    • Challenges the Commonwealth Care Alliance has faced in the advancement of such program include shifting payment rules that have posed barriers to combining global payments from multiple payers, making the comprehensive care model possible, state regulation struggles, heavy dependence on viable primary care physician practices, and need for non-English speaking physicians
    • Plans for the programs include expansion to include more chronically ill patients