Building Complex Care Programs: A Roadmap for States

Wilkness S, Pandit S, Arabo F, Malone S, Tewarson H
Publication Year: 2018
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care, Medicaid beneficiaries
Intervention Type: Service redesign, Staff design and care management
Type of Literature: Grey

States pursuing the three-part aim of improved health, high quality care, and reduced costs often start with programs for complex care populations. These programs target high-need, high-cost Medicaid enrollees who are the most frequent users of costly sites of care, such as emergency departments and inpatient settings, but whose needs are often best met in the community. Nationally, they account for approximately 50 % of Medicaid spending despite representing only 5 % of those enrolled. As discussions continue around changes to the Medicaid program at the national level, states are continuing to seek innovative solutions for complex care populations. Effective complex care programs prioritize increased access to primary care, timely transitions from acute care settings and a multidisciplinary approach which prioritizes care coordination and includes pharmacy, behavioral health and social support services in the community (such as housing, employment and transportation).

Since 2013, the National Governors Association Center for Best Practices (NGA Center) Health Division has worked with 10 states and one territory, providing technical assistance to develop state-level solutions for complex care populations. Building Complex Care Programs: A Road Map for States guides state leaders in establishing and advancing complex care programs. It includes lessons learned from our work with states and effective practices gleaned from multiple pioneering state and local complex care initiatives.

Insights Results

Overview of article

  • This roadmap guides state leaders in establishing and advancing complex care programs. It includes lessons learned from state programs and effective practices gleaned from multiple state and local complex care initiatives
  • The roadmap is a tool to help states improve the health of their residents in a cost-effective manner given budget constraints. It serves as a step-by step guide to help states assess their capacity to create complex care programs, select evidence-based practices to maximize outcomes, implement effective targeting and evaluation strategies and consider lessons learned from early adopters. The roadmap is designed as a program development tool, allowing states to use all or portions of the roadmap as it applies to their unique situations. It was developed in close consultation with providers, national experts, and local, state and federal officials

Key takeaways/implications

  • There are 4 main lessons learned: 1) Alignment across state and local health reform initiatives that affect complex care populations allows for comprehensive and precise care delivery and payment strategy development, creates efficiencies by avoiding duplication of effort and leveraging resources for common goals, streamlines workflows and reporting for providers and simplifies consumer engagement with the health and social services systems; 2) A data-driven approach is the cornerstone of successful, sustainable programs. From identifying the target population to monitoring progress, tracking outcomes and implementing a robust program evaluation, these strategies help to drive sustainable programs that measure and identify return on investment; 3) Make sure the right people are at the table, are bought-in early and are engaged in implementation. State policy work relies on strong stakeholder relationships. Internal engagement includes key decision makers from all relevant state agencies. External engagement includes key stakeholders from the provider, payer and consumer communities that have a vested interest in the program; and 4) Develop a care delivery and payment approach that incentivizes access to cost-effective interventions for the target populations
    Evidence-based solutions for this population span a very fragmented system of care across the medical, mental health, substance use and social support domains. Ensuring the delivery of meaningful care coordination and multi-disciplinary, person-centered care is key
  • There are 5 main elements of the roadmap:
    1) Develop internal resources, build stakeholder partnerships and conduct environmental scan – At this stage, states should assemble a group of key decision-makers from all relevant agencies to identify and serve as internal advisors to the core team. The core team will comprise a subset of key decision-makers (or their direct reports), including the governor’s health policy advisor. At this stage, states should also identify and commit staff resources to support the core team’s work, and establish/engage an existing external stakeholder advisory group to participate in program design. Finally, with internal and external input, state should conduct an environmental scan of healthcare delivery system reform efforts across the state and specify how they do or may affect the complex care population and align approaches accordingly. The scan should also aim to identify existing complex care programs among providers, payers, counties and communities
    2) Build theory of the case, identify the target population and design tracking and evaluation approach – This stage consists of 2 phases. The foundation phase should use existing information to build a theory of the case and determine data collection and analytic capabilities and fill gaps with strategic partnerships. The design phase should focus on identifying the target population (start with utilization and cost data, analyze characteristics and determine which are “impactable” and finally vet preliminary results with external stakeholders to match evidence-based interventions and assess availability). The design phase also encompasses determining the delivery and payment model by 1) Building an evaluation strategy that includes establishing a coerce set of metrics to evaluate impact and measure of return on investment; and 2) Designing an implementation monitoring and tracking approach that includes rapid-cycle evaluation for continuous program improvement and to capture early findings
    3) Develop and implement delivery and payment model – In this phase, states, with input from cross-stakeholder groups, should identify the scope of care delivery and payment model based on the identified population and availability of best practice interventions. Additionally, states should decide on 3 general approaches for the program: partnering with MCOs, partnering directly with providers or a regional approach. Next, states should select the specific care delivery and payment model by prioritizing evidence-based interventions, ensuring that care delivery and payment strategies align with major initiatives in the state that affect the target population, review delivery and payment models used successfully in states and determining feasibility of adoption based on current state programs and initiatives, and considering risk sharing strategies and the state’s role in supporting models. Finally, states should enroll the target population and administer the program
    4) Track implementation, evaluate program and communicate findings – During this phase, states should first execute the monitoring and tracking plan to maintain implementation and data collection for evaluation. States should also use their previously established core metrics to evaluate progress. Finally, states should tell the story and move toward sustainability
    5) – Data strategy and stakeholder engagement serve as the foundational elements of the roadmap and are essential and present throughout all stages. A data-driven strategy is at the heart of successful complex care programs and cuts across all elements of design and execution, from building a theory of the case to communicating outcomes. Key components include careful identification of the target population, matching to evidence-based interventions and determining access opportunities and gaps, monitoring and tracking to maintain implementation and for performance improvement, and rapid-cycle evaluation to capture early outcomes and a more comprehensive evaluation that measures program effectiveness in core elements