Healthcare Innovation Awards: Lifelong Medical Care

Publication Year: 2019
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care, Dual eligible, Medicaid beneficiaries, Vulnerable/disadvantaged
Demographic Group: Adult
Intervention Type: Service redesign, Staff design and care management
Type of Literature: Grey

The LifeLong Complex Care Initiative merges the strengths of a community health center, LifeLong Medical Care, and an independent living center, Center for Independent Living, to provide coordinated, interdisciplinary team care for adults with disabilities who are at high-risk of poor health outcomes and avoidable utilization of high-cost emergency room and inpatient care. The project targets the 20% highest risk patients among a population of 3250 seniors and other adults with disabilities who are Medicaid and dual Medicare/Medicaid beneficiaries living in Alameda County, California and are members of the Alameda Alliance for Health. By the end of the three-year demonstration, the collaboration seeks to improve health outcomes and utilization patterns such that consumers are healthier, more satisfied with their care, and less likely to utilize high-cost services, with a goal of approximately $1 million in cost savings. The intervention trains adults with disabilities as peer coaches, to support consumers to identify and work towards self-directed health goals, such as healthy lifestyle modifications, disease self-management, and increased independence. The peer coaches are partnered with RN care managers, who facilitate integrated care and provide practical services including health education, medication reconciliation, and self-management support.

Insights Results