Care Coordination

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Information Sharing to Improve Care Coordination for High-Risk Dual Eligible Special Needs Plan Enrollees: Key Questions for State Implementation

This technical assistance tool focuses on the new “information sharing” requirement for Dual Eligible Special Needs Plans beginning in 2021. The tool explains the new requirement as well as how to address the requirement in mandatory D-SNP contracts.

Short URL: http://www.advancingstates.org/node/71731

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Report to the President and Congress Section 1018 Action Plan for Technical Assistance and Support for Innovative State Strategies to Provide Housing-related Supports to Individuals with Substance Use Disorder under Medicaid

CMS provided the president and Congress a report detailing the center’s action plan to provide support and technical assistance to states delivering supports to Medicaid beneficiaries with substance use disorder (SUD). The report outlines how CMS plans to implement requirements of Section 1018(a) of the SUPPORT for Patients and Communities Act in 2020-2021.

Short URL: http://www.advancingstates.org/node/71621

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Patient-Centered Medical Homes and the Care of Older Adults: How Comprehensive Care Coordination, Community Connections, and Person-Directed Care Can Make a Difference

The Patient Centered Medical Home Network of The John A. Hartford Foundation Change AGEnts Initiative released a new paper titled, "Patient-Centered Medical Homes and the Care of Older Adults: How comprehensive care coordination, community connections, and person-directed care can make a difference.”

Short URL: http://www.advancingstates.org/node/68579

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The Duals Demonstration: A First Glimpse at Lessons Learned

Justice in Aging published an issue brief that offers an analysis of the findings from the evaluation of the Financial Alignment Initiative (FAI), commonly known as the dual eligible demonstration. Research Triangle Institute was contracted by the Centers for Medicare and Medicaid Services (CMS) to conduct this evaluation, which focused on the first six months of operation of the demonstration in each of the seven states where it was rolled out.

Short URL: http://www.advancingstates.org/node/67477

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Medicare and Medicaid: Additional Oversight Needed of CMS's Demonstration to Coordinate the Care of Dual-Eligible Beneficiaries

The Centers for Medicare & Medicaid Services (CMS) began the Financial Alignment Demonstration in 2013 to improve care coordination. GAO was asked to examine care coordination under this demonstration. On January 19, The Government Accountability Office publicly released a report with their recommendations for CMS. GAO recommends that CMS develop new measures and align the current measures to improve oversight of care coordination.

Short URL: http://www.advancingstates.org/node/67285

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Dementia Care Coordination Workforce and Practices in Seven Duals Demonstration States

The University of California San Francisco published a report about dementia care coordination for duals populations with a specific look at the inadequate workforce of dementia-capable care coordinators.Currently, there are twelve states in the process of implementing demonstrations projects. This report examined three-way contracts from seven states that were selected for their expertise in care coordination.

Short URL: http://www.advancingstates.org/node/67132

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Care at Hand: Service Delivery Innovation Profile

Supported by mobile technology, trained health coaches at Elder Services of Merrimack Valley (an AAA in Northeastern Massachusetts) visit recently discharged Medicare patients in their homes and monitor them via telephone to identify and address declines in health status that increase the risk of readmission. Review the AHRQ study that gave the program a moderate evidence rating for improving outcomes, decreasing cost of care.

Short URL: http://www.advancingstates.org/node/65596

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