Assessment, Care Planning, and Care Coordination

This brief shares strategies for hiring and training care managers for health plans with integrated care programs serving Medicare-Medicaid beneficiaries.

This brief describes how three states - California, Ohio, and Virginia - are requiring Medicare-Medicaid Plans to stratify Medicare-Medicaid enrollees by their level of need within capitated financial alignment demonstrations.

This brief explores how health plans are: (1) addressing dually eligible members’ service needs that are beyond the scope of traditionally covered Medicare or Medicaid services; (2) assessing the value of offering these services; and (3) allocating these services equitably across members.

This brief discusses concrete, actionable steps that states can take to move toward more integrated care for Medicare-Medicaid enrollees.

This brief describes key considerations for developing interdisciplinary care teams and explores how eight states addressed issues such as engaging providers and measurement approaches.

This report summarizes care coordination models and care coordinator responsibilities in Medicaid managed long-term services and supports programs in 18 states.

This webinar shares health plan strategies for contacting hard-to-locate Medicare-Medicaid enrollees, building relationships, and creating person-centered care plans that incorporate social service and housing needs.

Concerns about care transitions between acute and long-term services and supports (LTSS) settings have been raised since at least the 1990s. More recently, studies have emphasized the growing need to address care transitions from nursing homes to community-based settings, as well as to divert people from nursing homes. This brief looks at six ways states can measure and improve effective transitions between acute care, long-term care, and the community.

The Community-Based Care Transitions Program (CCTP) supported by the CMS Center for Medicare & Medicaid Innovation tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.