Workgroup's Recommendations Help HMOs Identify and Care for, High-Risk Chronically Ill Older Patients

    • May 30, 2006

For 10 years (1994–2004), the HMO Workgroup on Care Management published recommendations on, and highlighted opportunities and challenges in, care management practices for chronically ill older patients under capitated arrangements—those in which the provider is paid a fixed amount for a patient over a given period no matter what the actual number or nature of services delivered.

The workgroup was composed of representatives from selected health plans and capitated group practices and researchers.

The Robert Wood Johnson Foundation (RWJF) supported this project—first as part of the national program Chronic Care Initiatives in HMOs, and then, after the program ended, through grants to the Washington-based AAHP Foundation (now called America's Health Insurance Plans [AHIP]). The project director estimates that the workgroup cost a little over $1 million paid from these grants.

Key Result

  • The HMO Workgroup on Care Management generated documentable improvements in care for chronically ill seniors in major health plans and capitated medical groups (e.g., Kaiser Permanente, Lahey Clinic, Group Health Cooperative of Puget Sound, Oxford Health Plans).

Key Recommendations

  • Managed care organizations should:

    • Find ways to identify, assess and plan for care for chronically ill seniors.
    • Establish partnerships with community agencies that provide complementary services for older members with common geriatric conditions.
    • Provide both practitioners and members with specific tools and guidance to enhance the functioning and quality of life of older members. It focused on seven common problems:
      • Physical inactivity.
      • Falls.
      • Depression.
      • Medication-related complications.
      • Urinary incontinence.
      • Under-nutrition.
      • Dementia.
    • Establish performance standards for transferring patients among care settings and monitor performance against these standards.
    • Develop and maintain user-friendly information systems that facilitate practitioners' ability to access necessary data elements and communicate with one another across the continuum of care.