Using Health Homes to Integrate Care for Dually Eligible Individuals: Washington State’s Experiences

Archibald N, Moses K, Reva L
Publication Year: 2019
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Dual eligible
Intervention Type: Service redesign
Type of Literature: Grey

To provide more integrated, coordinated care for its residents who are dually eligible for Medicare and Medicaid, Washington State is operating a demonstration under the Financial Alignment Initiative offered by the Centers for Medicare & Medicaid Services. This case study describes: (1) the demonstration’s structure; (2) results achieved to date; and (3) insights on the demonstration’s implementation from the state and other stakeholders.

Insights Results

Overview of Model

  • To provide more integrated, coordinated care for its residents who are dually eligible for Medicare and Medicaid, Washington State is operating a demonstration under the Financial Alignment Initiative offered by the Centers for Medicare & Medicaid Services
  • The demonstration, launched in July 2013, uses a managed fee-for-service model based on Medicaid Health Homes. It does not change how enrollees’ medical and behavioral health care or long-term services and supports are delivered, but instead uses health homes to better integrate care across these settings. Washington State contracts with Health Home Lead Entities that, in turn, contract with networks of Care Coordination Organizations (CCO), and together they provide the 6 required core health home services, including comprehensive care management and care coordination. The demonstration targets dually-eligible beneficiaries having at least 1 chronic health condition and who are at risk for developing another condition and incurring significant medical costs


    • Report covering the time period July 1, 2013 through December 31, 2015 found that enrollees were satisfied with their health homes and care coordinators and feel they were achieving their goals
    • Demonstration significantly reduced expensive institutional care (e.g., hospital inpatient and skilled nursing facility admissions and the probability of any long-stay nursing facility use); however, it increased rates of hospital readmission
    • Separate from the programmatic evaluation, CMS determined that Washington was eligible for retrospective performance payments based on Medicare savings and quality benchmarks. The Washington demonstration achieved an estimated $34.9 million in Medicare savings its first 18 months, $30.2 million in the next 12 months, and $42.0 million in the 12-month period after that; however, due to lags in Medicaid data availability, these figures do not include Medicaid savings or costs and will be updated when these data are available. As of November 2018, CMS has made three interim performance payments of $11.6 million, $10.7 million, and $14.2 million to Washington State
      Key Takeaways
    • Engaging stakeholders is important to building support for integration activities. A Health Home Advisory Team – comprised of representatives from various stakeholder groups – offered regular input to program design and lobbied for the demonstration when it was in jeopardy
      Targeting higher-risk groups offers greater potential to demonstrate results. Based on the success of its prior chronic care management demonstrations, the state used its advanced data analytics systems to identify and target enrollment to dually eligible beneficiaries with the highest risk and highest costs
    • Locating and engaging beneficiaries in care management is resource intensive. Engaging enrollees was more difficult than many had anticipated and required CCOs to adjust their staffing models by hiring staff with expanded skill sets and creating dedicated outreach specialist positions
    • Encouraging enrollee engagement may improve outcomes. Health Action Plans (HAPs) promote person-centered planning and improve self-management skills by focusing on an enrollee’s goals for his or her own health as well as the action steps needed to achieve those goals
    • Structuring the health home payment can incentivize enrollee engagement and in-person care coordination. Washington’s one-time payment for initial enrollee outreach provides an incentive for CCOs to locate enrollees and engage them in their care, while tiered per member per month payments encourage intensive, in-person care coordination
    • Securing financial support for long-term sustainability is a continuing effort. Initial financial support for the demonstration came from the 90% enhanced federal Medicaid match rate for health home services, but that match ended after 8 quarters, and the state has since earned federal Medicare performance payments under the demonstration that provide ongoing financial support
    • By engaging individuals in their care and focusing on the goals that matter most to them, health home care coordinators help enrollees to make meaningful behavior changes that improve health outcomes and reduce costs. While early evaluation results point to the effectiveness of this model, its long-term sustainability depends on the state’s ability to continue to access Medicare performance payments