Senior Care Options (SCOs)

On Thursday October 14, 2004 the Community Resource Center, under the able stewardship of Corinne Castro, resumed hosting a regular series of resource presentations after a long hiatus. The first presentation was by Diane Flanders, Director of Coordinated Care Systems for MassHealth’s Elder Affairs Division, on a new program that seeks to leverage the benefits available to those eligible for both MassHealth and Medicare to get them the health and social services they need.

Over 8 years in the making, the Senior Care Options (SCO) model finally became a reality in this spring as three health care organizations enrolled their first SCO clients. This five-year demonstration project is a joint state-federal partnership that seeks to improve outcomes and patient satisfaction while not exceeding current costs. Ms. Flanders described it as a practitioner-based model, but with a managed care design. The site of care is a physician practice. SCOs bring together the PCP, a nurse and social worker (Geriatric Social Service Coordinator- or GSSC) to form a Primary Care Team (PCT) housed in the PCP’s office. The GSSC by mandate must be a licensed social worker and be contracted through an Aging Service Access Point (ASAP- formerly the state home care corporations).

The payment is capitated (i.e., flat rate per member per month regardless of services utilized). There are different levels of payment determined by location and medical status (e.g., patients are rated on a scale - “Community Well”, “Community Frail”, “Nursing Home Eligible”, and “Institutionalized”). Related Medicaid payments range from $225 per month for a typical “Community, Well” patient, to $2000/month for “Community Frail” to $7,500/month for a very frail institutionalized patient. In addition, there are Medicare capitation payments, wh ich are pooled with the Medicaid payments at the SCO level. The benefit of a capitated payment is that providers have the flexibility to spend these funds as they see fit without the usual barriers of prior approvals and denials, fee-for-service limits and the need to document “medical necessity”. One example Ms. Flanders gave was of the patient with severe asthma and multiple emergency room visits and admits. The SCO might decide to buy her an air conditioner to save on greater medical costs; a common sense solution unlikely to occur under regular MassHealth.

Eligibility

• Age 65 or over (disabled persons under 65 are not eligible)
• Medicare and MassHealth (Medicaid) eligible , with or without Medicare
• Persons who have end stage renal disease or who are long term residents of chronic hospitals are not eligible to enroll in SCO. However, if ESRD or placement in a chronic hospital occurs after SCO enrollment, the person may continue in SCO.
• Anyone who is eligible cannot be denied access to the program.
• Enrollment is voluntary. Patients may disenroll at any time.

Benefits

• Access to vision, dental, podiatry and hearing services
• No pharmacy co-pays
• Health care management and coordination available 24/7.
• Geriatric expertise and maximum flexibility to assist doctor to prevent/delay disability and deterioration
• Attempts, where appropriate, to leverage community services to enable consumer to remain at home
• Values consumer participation in care planning
• Relief from Medicare paperwork and Medicaid prior approval/screening requirements
• Electronic medical record available 24/7 to SCO staff- who can relay pertinent information via phone to providers in an urgent or emergent situation.
• Strives for “quality interventions and outcomes, in accordance with the interdisciplinary geriatric model of care”. Behavioral health needs are part of the overall assessment. One of their performance measures includes Behavioral Health Utilization- the goal is to increase their use, recognizing that one of the major predictors of nursing home placement is mental illness.
• The SCOs must have contracts with all types and levels of provider. This includes transportation vendors, adult day health, nursing facilities, assisted living facilities and behavioral health providers.
• Some MGH physicians are included and two of the three SCO programs have contracts with MGH for inpatient care.

Currently there are three SCOs in operation with a total of approximately 500 enrollees. Geographically most of the state is covered- the current exceptions are the parts of the Berkshires and the Cape and Islands. The hope is to have these areas covered within the next two to three years. The SCO programs are: Evercare- based primarily in Boston, Springfield, Lawrence and Worcester. This is a for-profit health care insurer group with commercial, M+C and Medicaid lines of business including the CMS-sponsored Evercare demonstration. Evercare is currently the largest SCO with about 300 enrollees. They work with VNAMI for skilled homecare. Commonwealth Care Alliance is a non-profit consortium of PACE providers and 6 medical groups. The third group Senior Whole Health,: is a for-profit alliance between Caritas Christi, the Catholic Health System in Massachusetts, and a start-up managed care firm.

During the question- and-answer period of the presentation, staff asked for help distinguishing this program from the Program for All-inclusive Care of the Elderly (PACE) model (also called ESP- Elder Service Plans). What distinguishes the SCO model is, that unlike under PACE:

• The patient does NOT have to be in the community. Someone already in a nursing home may apply – benefits to that person might include case-management, health care advocacy, follow-up and family support respite.
• The patient does NOT have to be “nursing home certifiable”. “Community Well” patients are welcome.
• SCOs only need 3 members on the health care team. Presumably this provides more rapid and flexible decision-making and improved communication than the PACE model, which, by law, must include 11 members on the health care team.
• SCO patients may not need to give up their existing relationship with their PCP.

Most PACE programs are based in adult day health and patients receive their services and monitoring primarily through that program. This limits PACE capacity – keeping them small. SCOs can provide access to more members.