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The Future Is Now: A Step in the Right Direction for a Vulnerable Population

If we can bring quality health care to those who need it most while making payment and reimbursement less confusing or burdensome for all, we are definitely taking steps in the right direction.
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When I imagine what the future of day-to-day health care might look like for low-income seniors living at home -- struggling with chronic conditions but wanting to stay connected to their community and their word -- here's what I see.

I see a 79-year-old woman like Mrs. S., who was bed-bound for several weeks as one issue or another related to her arthritis, congestive heart failure and diabetes limited her once-"neighborly" lifestyle. The registered nurse who supervises her home health care action plan calls to reinforce personal goals for the day, and with the help of her certified home health aid who has training as a health coach, Mrs. S. moves her day into motion.

After making her way from bedroom to bathroom, she and her aide head to the kitchen for breakfast and coffee, then the living room to watch today's episode of "Lo Que La Vida Me Robó" (a goal they reached three weeks earlier). After lunch, her physical therapist arrives for today's "big event," a short walk outdoors to mail a birthday card to her great niece. "Good day to you, dear," she says to her neighbor at the elevator, exchanging a smile. "We're off to see the world, starting with a mailbox!"

And there are countless others. I see a grandfather with congestive heart failure who can no longer manage the stairs up to his fourth-floor apartment, successfully relocating to his new place on a lower floor. He's now able to come and go each day, which is good news as much for his friends at the corner bodega where he mulls over daily headlines as it is for him.

I see an octogenarian couple on a fixed income shopping the aisles of the pharmacy, confident in the knowledge that they have a monthly stipend that will cover the everyday items that keep them healthier, such as toothpaste, Band-Aids and sunscreen.

I see people no longer living in fear and isolation, who are active participants in their health care, whose care needs are overseen by a single, highly skilled and dedicated care manager, who is in frequent dialogue with an interdisciplinary care team that includes the participant's primary care doctor.

We can see all of this because the future is now. As our healthcare system evolves, experts in the field are working to create ambitious new health insurance models to support a particularly vulnerable -- and costly -- healthcare population: elderly Americans with multiple chronic illnesses who require long term health support services and depend on both Medicare and Medicaid.

Nearly a year ago, New York State launched a statewide integrated care program for this population, named the Fully Integrated Duals Advantage program, or FIDA -- so called because those affected are dually eligible for Medicare and Medicaid. In creating this program, the New York Department of Health and the Centers for Medicare & Medicaid Services joined forces to roll all the benefits of Medicare and Medicaid into a single comprehensive plan. That means one plan, one insurance card and one phone number connects participants to access and assistance with their needs, including doctor visits, hospitalizations, behavioral health, long-term care services and supports, social services, and prescription drugs.

Finding a way to successfully integrate health services for this group of Americans is vital to overall health reform's goal of bringing higher quality care to more people and at lower costs. Nationwide, there are an estimated 9 million people who are dual-eligible beneficiaries, with an estimated $319.5 billion a year spent on their care, according to the Urban Institute. And while they represent only 15 percent of all Medicaid enrollees and 18 percent of Medicare beneficiaries, this population accounts for 39 percent of total Medicaid expenditures and 31 percent of Medicare expenditures. In New York, dually eligible individuals account for 45 percent of total Medicaid expenditures, according to numbers reported in 2012 by the NYS Health Foundation.

The stories that we have seen in VNSNY CHOICE's FIDA program, which currently has approximately 2600 participants, are powerful evidence that some type of integrated care model is the right approach.

This includes Mrs. Z., a bedbound woman who, until she joined FIDA, could not receive well-coordinated coverage for a special chair that would have allowed her to get out of bed and sit up. When her FIDA care manager and home health aide tirelessly advocated for her, the story changed. "When your Medicare is covered by one plan and your Managed Long Term Care is with another plan, there can be a disconnect around how to get something paid for," says Todd Piorier, who is Director of Care and Utilization Management for VNSNY CHOICE FIDA Complete health plan. "Mrs. Z. was having such trouble getting a chair that would accommodate her. Now that she has it, the act of being transferred out of bed, and simply sitting in a chair, can be so powerful. She can see things differently. Her home health aide marveled at the change in her demeanor."

Another FIDA care manager made it possible for Mr. G., who could no longer manage the stairs to his fourth-floor apartment and was at risk of becoming homebound, to move to a first-floor apartment. Once the landlord had arranged an appropriate apartment, the moving company's high fees threatened to make the plan impossible -- until the care manager had many phone calls to negotiate a lower fee.

All these skills are in the job description of FIDA care managers. They also make sure that participants are aware of plan benefits such as the monthly stipend for over-the-counter health supplies, and help connect them to free local transit services and senior centers in their neighborhood. "We want to keep people in the least restrictive environment -- and that is out in the community that they know and love," says Todd, who is a registered nurse. "Any issues you have, that dedicated care manager is there to advocate for you. It's really magical when you see it all come together."

New York is not the only state exploring this option. Nine other states currently have fully integrated dual-eligible demonstration programs either underway or about to start: California, Illinois, Massachusetts, Michigan, Ohio, Rhode Island, South Carolina, Texas, and Virginia. The future of healthcare reform requires integrated care models like these, which encourage independence and active participation, as well as demonstrate a deep understanding of the needs and limitations of our most at-risk elderly populations.

If we can bring quality health care to those who need it most while making payment and reimbursement less confusing or burdensome for all, we are definitely taking steps in the right direction.