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Rethinking Patient Experience in Transforming Care for People with Complex Care Needs

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As retailers and brands build deep, enriching relationships at each step of the customer journey and become an indispensable part of consumers’ lives, their ability for deep understanding of the way consumers live, eat, work, and play is central to being able to provide value in the right place and at the right time. Their ability requires a consumer-centered view of the entire business and a technology capability to capture and analyze consumer data in real time.

In healthcare, the disproportionate impact that the COVID-19 pandemic has had on certain populations has only served to underscore just how much the environment in which people live largely determines the health and well-being of residents in communities across the US. And because social determinants of health (SDH), rather than medical care, are likely to contribute more to an individual’s health outcomes, healthcare providers are increasingly working to factor SDH into the way they engage with and support patients.

Health disparities, which are more significant in communities that experience a greater level of SDH, can cut across multiple sociodemographic categories, such as race, ethnicity, gender, sexual orientation, age, disability status, socioeconomic status, and geographic locations. As a result, a more holistic, community-centered, and data-driven approach to care that factors in and addresses SDH is emerging in order to make significant improvements on both the individual and population health levels.

Across the US, different stakeholders in healthcare are rethinking care delivery models for people with complex health and social needs and whose health is closely tied to a mix of significant medical, behavioral health, and social challenges. These include frail, older adults, as well as people with multiple chronic conditions, physical or developmental disabilities, serious illness, and serious behavioral health problems. Compared with the broader population, patients with complex care needs tend to have higher rates of service use, yet they experience worsening outcomes.

Unite Us, a technology company that builds coordinated care networks of health and social service providers,is rolling out networks in communities across the US to transform their ability to work together and measure impact at scale. The Unite Us technology platform connects community partners by providing social services, such as housing, employment, food assistance, and behavioral health, with healthcare providers in real time to deliver integrated whole-person care. Using Unite Us, providers across sectors can send and receive secure electronic referrals, track every person’s total health journey, and report on outcomes across a full range of services in a centralized, cohesive, and collaborative system.

These person-centered care models are increasingly aligned with value-based payment models that prioritize greater coordination and integration between providers in geographic service areas to achieve better health outcomes and well-being for people with health and social needs. Examples of value-based payment models adopting whole-person care models include the following:

  • California is embarking on a transformation of the State’s Medicaid program, Medi-Cal, through the California Advancing and Innovating Medi-Cal (CalAIM) initiative. To date, beneficiaries, depending on their individual needs, have often had to access multiple separate delivery systems to get those needs addressed. The CalAIM initiative will focus on an integrated, patient-centered, and whole-person care approach that coordinates services, addressing social determinants of health to reduce health disparities and inequities. In doing so, the state is seeking to integrate delivery systems and align funding, data reporting, quality, and infrastructure to mobilize and incentivize stakeholders toward common goals. As part of that transformation, California will invest nearly $3 billion of American Rescue Plan Act funding to enhance, expand, and strengthen home and community-based services (HCBS) aligned around CalAIM. The first reforms will be implemented in 2022, and additional reforms will be phased in through 2027.
  • Medicare Advantage (MA) not only provides beneficiaries with all services covered under traditional Medicare, but also increased coverage of long-term care services and supports (LTSS) through the development of MA supplemental benefits. In 2020, MA supplemental benefits introduced benefits that allow greater flexibility in plan design to offer social supports to address “non-primarily health-related” social determinants of health for chronically ill enrollees. MA “non-primarily health-related” supplemental benefits offer greater flexibility for providers to pay for services and goods, such as in-home support, transportation, and meals, or devices and data plans to connect individuals. The US Congressional Budget Office projects that the share of Medicare beneficiaries who will be enrolled in MA plans will increase from just over 40% today to 51% by 2030. MA enrollment in 2020 was highly concentrated in major private payers as follows: UnitedHealthcare and Humana (44%), Blue Cross Blue Shield affiliates (15%), and CVS Health, Kaiser Permanente, Centene, and Cigna (23%).

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