Adapting a Model of Integrated and In-Home Care for Safety-Net Patients with Multiple Chronic Conditions

2016-2018
Prepared for
California HealthCare Foundation

California’s Medicaid program, Medi-Cal, is the largest state Medicaid program in the nation and the main source of coverage for low-income children, adults, and people with disabilities. It also provides wraparound coverage for many elderly Medicare beneficiaries.

This project is examining an innovative care delivery model built on a partnership between Landmark Health and the Inland Empire Health Plan to deliver coordinated services to eligible Medi-Cal managed care members with multiple medical and behavioral health needs. These individuals are among the least well cared for in California’s safety net population as well as the most expensive.

Under the model, Landmark  delivers intensive care for members with five or more chronic conditions. Interdisciplinary care teams provide in-home medical services as well as 24/7 crisis management services in addition to coordinating health and social services. The goal is to enhance delivery and coordination of care, improve quality of life, and generate aggregate savings by improving medical management, thus reducing costly events such as emergency care and hospitalizations. Landmark shares financial risk for the health care services used by members.

The model has had some success within a Medicare Advantage population outside of California. However, adapting the model to the Medicaid population represents a new challenge. We are evaluating impacts on utilization, quality of care, costs, and member and provider experiences. The project includes an implementation evaluation, to identify practical lessons learned in adapting this model to serve Medicaid enrollees and to support ongoing learning, as well as an impact evaluation.