Hospitalization can be dangerous and disruptive for nursing facility residents. Almost 45 percent of hospitalizations of nursing residents enrolled in both Medicare and Medi-Cal are potentially avoidable. Los Angeles and Orange Counties are among the highest-cost areas for nursing facility residents nationwide, driven by high rates of hospitalizations and subsequent stays in Medicare-paid skilled nursing facilities.
In 2017, the Centers for Medicare & Medicaid Services (CMS) and the California Department of Health Care Services (DHCS) will launch a new initiative to improve health outcomes and reduce costs for nursing facility residents in Los Angeles and Orange Counties. Through this initiative, health plans participating in the Cal MediConnect program, a capitated financial alignment model demonstration, will develop and implement interventions to reduce avoidable hospitalizations for nursing facility residents.
These quality improvement activities will be assessed annually. At the same time, CMS and DHCS will test new payment adjustments to better reflect typical costs of care for this population. Previously, payments to health plans underestimated Medicare spending, and Cal MediConnect plans served a disproportionately low number of nursing facility residents. These quality improvement activities and new payment adjustments amend the existing parameters for Cal MediConnect.
DHCS and CMS in 2014 began the Cal MediConnect demonstration, which tests a new model for providing Medicare-Medicaid enrollees with a more coordinated, person-centered care experience, along with access to new services. Under the demonstration, California and CMS contract with Medicare-Medicaid health plans to coordinate the delivery of and be accountable for Medicare- and Medi-Cal-covered services for participating Medicare-Medi-Cal enrollees.
Plans are responsible for providing a comprehensive assessment of enrollees’ medical, behavioral health, long-term care services, functional, and social needs. Enrollees and their caregivers work with an interdisciplinary care team to develop person-centered, individualized care plans. About 115,000 Californians are enrolled in Cal MediConnect.
For more information on Cal MediConnect, please visit https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/California.html or www.calduals.org.