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Service Delivery Innovation Profile

Plan-Funded Team Coordinates Enhanced Primary Care and Support Services to At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits

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Commonwealth Care Alliance developed a health plan (known as Senior Care Options) that provides low-income, dually eligible (i.e., individuals eligible for both Medicare and Medicaid coverage), elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric specialist who work out of the enrollee's primary care clinic. The team ensures that these at-risk, medically complex individuals receive needed medical care and social services, with the goal of keeping them healthy and allowing them to remain in their homes for as long as possible. Services are provided as part of the plan's contracts with the Medicare and Medicaid programs, at no additional cost to the enrollee. The program has led to increases in the provision of recommended preventive and screening services, improvements in the management of chronic disease, shorter hospital stays, fewer hospital admissions and emergency department visits, and lower costs and length of stay.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparison of costs pre- and post-implementation, as well as years of post-implementation trend data on a variety of outcomes measures.
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Developing Organizations

Commonwealth Care Alliance
Boston, MAend do

Use By Other Organizations

    There are three other Senior Care Options programs in the Commonwealth of Massachusetts.

Date First Implemented

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Patient Population

Information provided in March 2012 indicates that plan enrollees are 65 years of age and older, with an average age of 77 years; 68 percent are female.Insurance Status > Medicaid; Vulnerable Populations > Medically or socially complex; Insurance Status > Medicare; Age > Senior adult (65-79 years)end pp

Problem Addressed

Medicare and Medicaid's fee-for-service (FFS) system and managed care plans often require enrollees to go through a complex and fragmented process to obtain needed medical and social support services. This process is geared toward self-sufficient enrollees who are able to schedule their own appointments and manage their own care and have access to transportation. Low-income enrollees who are frail, disabled, or have multiple chronic health conditions need more support and coordination services than these programs typically offer. Without additional support and care coordination, this vulnerable population is at high risk of costly and avoidable hospitalizations and nursing home placements.
  • Many medically vulnerable, low-income seniors: Nationwide, 40 percent of Medicaid spending goes to seniors who are dually eligible for Medicaid (because of poverty) and Medicare (due to older age).1 In Massachusetts, 50 percent of Medicaid funding goes to this vulnerable, dually eligible population.1
  • Failure of current structures to serve this population well: Most Medicaid and Medicare managed care plans fail to provide the level of service needed by the frail elderly population. For example, most plans require these patients to initiate their own primary care appointments and obtain their own transportation to these appointments. In addition, some FFS plans do not require members to have a primary care physician.1 The problem extends beyond the provision of medical care to community services. For example, frail elderly patients often do not understand what support services are available in the community or which ones would improve their health and quality of life. Even if they are aware of available programs, they often do not know how to apply for them.
  • Excessive reliance on family, friends, and institutional care: According to a national survey, nearly two-thirds of noninstitutionalized individuals with functional limitations rely on informal care from family, friends, and volunteers, with fewer than 10 percent exclusively using formal, paid care.1 Those who do not have an adequate support system often end up in hospitals and/or nursing homes. For example, Massachusetts' dual eligible elderly residents experience a higher rate of nursing home placement and hospitalization than do traditional Medicare beneficiaries.1

What They Did

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Description of the Innovative Activity

Commonwealth Care Alliance's Senior Care Options plan provides low-income, dually eligible, elderly enrollees in Massachusetts with a primary care team made up of a physician, nurse practitioner, and geriatric social workers who work out of the patient's primary care clinic. The team is empowered to ensure that these at-risk, medically complex individuals receive needed medical care and social support services, with the goal of keeping them healthy and allowing them to remain in their homes for as long as possible. Services are provided at no additional cost to the enrollee. Key elements of the program are described below:
  • Population served: The Senior Care Options plan, available in Greater Boston and three other regions of Massachusetts, is available to seniors who are dually eligible for Medicaid and Medicare due to their age and income. Information provided in March 2012 indicates that, as of January 2012, the Senior Care Options membership was 3,665, and approximately 72 percent of members are eligible for nursing home placement but are supported in the community through this program. Currently, 62 percent of enrollees speak a primary language other than English, 45 percent are diabetic, and 15 percent have congestive heart failure. 
  • Provider network led by primary care practices: Commonwealth Care Alliance manages a selectively chosen network of providers who have made a commitment to providing the level of service needed by plan members. Information provided in March 2012 indicates that, as of January 2012, the alliance works with 26 primary care sites, some of which comprise over 10 individual practices, which provide and coordinate services for between 1 and 600 Senior Care Options enrollees each. The network also includes hospital systems, specialists, home health care, durable medical equipment, behavioral health, and community-based services (e.g., home health aides; personal care attendants; and transportation, chore, and meal delivery services) to members as needed. 
  • Assignment of enrollee to primary care site: Enrollment in the program is voluntary. Those who choose to enroll are assigned to a primary care clinic based on the clinic's caseload and proximity to the member's home. If an enrollee is already a patient at a participating site, he or she can keep the same doctor. If not, the enrollee is assigned to a new primary care provider at a participating site.
  • Development of care plan for each enrollee: On enrollment, a nurse practitioner assesses the medical, behavioral, and social circumstances of each member. Geriatric support service coordinators evaluate each member's living capabilities to determine whether community-based services, such as transportation, adult daycare, and meal preparation and delivery, are needed. Some of these screenings are performed in members' homes to assess the safety of the home environment and the availability of family or caregiver support. The enrollee and nurse practitioner also meet with the primary care physician for an initial evaluation, either at the clinic or in the home.
  • Ongoing care and care coordination, assessment, and monitoring from primary care team: The patient's primary care team includes at least one physician, a nurse practitioner with geriatric expertise, and a geriatric coordinator. The team is responsible for providing and coordinating medical and social services to enable independent living. Some participating primary care sites maintain permanent care teams, while others assemble teams on a patient-by-patient basis. Key elements of the services provided by the teams are described below:
    • Ongoing care and care coordination from nurse practitioners: Nurse practitioners coordinate care, execute the care plan (including ordering home equipment and lining up respite help for family members), and deliver most primary care services. Seriously ill or disabled patients see nurse practitioners weekly, whereas more stable patients see their nurse practitioners four times a year. Each nurse practitioner typically cares for between 40 and 65 patients at a time.
    • Ongoing reassessment and monitoring by full team: The frequency of visits with the full team varies according to enrollee needs. Most enrollees are reassessed at least twice a year through home or office visits. Enrollees are also instructed to call team members with any questions or concerns about their health. Nurse practitioners also make unscheduled home visits to assess an enrollee's safety. Physicians also are on call 24 hours a day for emergency consultations.
    • Provision of additional primary care and social support services as needed: The primary care team is empowered to authorize any of a variety of additional medical and social services that an enrollee may need, including the following:
      • Personal care attendants: Personal care attendants are provided if authorized by the geriatric support service coordinators. Attendants, who can be friends or family members, are hired by and report directly to enrollees, with the costs covered by Senior Care Options. The care team maintains phone and inperson contact with attendants, monitors their performance, and updates them about medication changes or upcoming appointments.
      • Skilled nursing assistance: When patients have more complex conditions and need more clinical support, the plan pays for skilled nursing assistance from an agency affiliated with the alliance. These services are coordinated by the nurse practitioner.
      • Other services: When needed, the plan pays for social worker services, physical and occupational therapy, and durable medical equipment, including wheelchairs and other equipment that can help enrollees remain in their homes.
    • Referrals to specialty and hospital care: Physicians and nurse practitioners can refer patients to inpatient or specialty care providers affiliated with the alliance. Administrative staff in the primary care clinic coordinate the member's appointments and arrange transportation. Team members discuss care plans ahead of time with the hospitals or specialists. In some cases, nurse practitioners accompany severely disabled patients to their appointments with specialists. The alliance pays for specialty and hospital care on a FFS basis, typically using Medicare rates.
    • Care coordination during emergencies and hospitalizations: Enrollees are instructed to call a team member before seeking emergency department (ED) care. The team determines whether an ED visit is necessary through a phone consultation or home visit. If a member goes to the ED without notifying the team, hospital staff usually contact the team (hospital staff tend to have close relationships with the primary care centers). The team's doctor or nurse often visits hospitalized patients within 48 hours of admission, while nurses schedule patient home or office visits to occur within 2 days of discharge. Either the physician or nurse can approve patient transfers to rehabilitation facilities if needed. After discharge, the physician or nurse practitioner continues to monitor the enrollee and coordinates needed medical care and support services in an effort to prevent the need for readmission. In 2009, to focus on the challenge of hospital readmissions, Commonwealth Care Alliance added the role of inpatient nurse partner at one of their major hospitals to effect care transitions for their members; the inpatient nurse partner facilitates communication between the hospitalist and the primary care team and ensures that members are discharged when appropriate, return home whenever possible and, when not possible, are directed to a preferred skilled nursing facility with which the alliance works.
  • Electronic medical records (EMR) support across provider sites: The alliance created Web-based electronic patient records that are accessible from numerous provider sites. Nurse practitioners enter patient information after primary, inpatient, and specialty care visits and attach test results, medication lists, and other vital information to the record as needed. On-call nurses, physicians, and other network providers have access to the EMR.
  • Practice-based financial incentives to keep members healthy: Information provided in March 2012 indicates that the alliance pays participating sites a fixed amount of money each to provide program services to enrollees. In addition, it offers financial incentives to select primary care sites if they are able to keep members healthy as well as risk-sharing arrangements that allow practices to benefit if they do a good job managing enrollees' care. For example, since 2007, one site has participated in a full risk arrangement with the alliance, receiving a fixed capitated fee per enrollee each month to cover all medical services needed. Under this arrangement, the practice retains any savings but also must absorb any losses when enrollee costs exceed the payment amount. Two primary care sites have partial risk-sharing agreements under which any generated savings or losses are shared between Senior Care Options and the practice.
  • Quarterly evaluations of outcomes and costs: Each quarter, the alliance assembles a report on each practice site's costs, service utilization, and other health care metrics. The report compares each member's monthly medical expenses with the alliance's entire Senior Care Options population. These reports help determine what payment structure should be negotiated with each site and helps the alliance evaluate the effectiveness of of the site's care delivery.

Context of the Innovation

Since the early 1980s, several Medicare demonstration programs have partnered with state Medicaid programs to develop new models of financing and care delivery for frail seniors who are dually eligible for Medicare and Medicaid. Many of these programs used prepaid, flexible financing, but none provided care coordination services, and most continued to place much of the onus for managing care on the enrollees themselves. In Massachusetts in 2003, the not-for-profit Senior Care Options plan was created through a unique partnership between the Centers for Medicare & Medicaid Services (CMS) and the Massachusetts Office of Medicaid. The plan was charged with delivering comprehensive care and care coordination services to this vulnerable population. Commonwealth Care Alliance, Inc., also created in 2003, operates the Senior Care Options plan in Massachusetts. The plan, which was developed by the alliance's chief executive officer, Robert J. Master, MD, replicates many of the care coordination strategies that Dr. Master had implemented when he headed the now-defunct Community Medical Alliance in Boston during the early 1990s. Community Medical Alliance, a nontraditional health plan that covered medically vulnerable enrollees, provided comprehensive services, including home health care, mental health and substance abuse treatment, adult day health, and case management at a lower cost per enrollee than did FFS Medicare programs.

Did It Work?

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The program has led to increases in the provision of recommended preventive and screening services, improvements in the management of chronic disease, shorter hospital stays, fewer hospital admissions and ED visits, and lower costs and length of stay. The following results, provided in March 2012, come from data on 2,372 program enrollees in 2009, 2,948 enrollees in 2010, and 3,665 enrollees in 2011.
  • Enhanced provision of recommended screenings and preventive care: Between 2005 and 2011, influenza immunization rates increased from 65 to 77 percent, while mammography screening rates increased from 75 to 79 percent among women between the ages of 65 and 69 years. Colorectal cancer screening rates increased from 30 to 51 percent. The percentage of program enrollees who had eye examinations, including glaucoma tests, in the past 2 years rose from 69 in 2008 to 73 in 2010.
  • Critical preventive care for the elderly: Several measure of quality of care particularly important to a frail elderly population have increased steadily and achieved a very high rate or performance. Annual medication review rate, annual functional status assessment rate, and annual pain screening rate are all at 98 percent. The rate of medication reconciliation after a hospital discharge has increased from 45 to 76 percent.
  • Improvements in chronic disease management: Key quality measures of diabetes care have steadily improved as follows: The annual HbA1c testing rate is over 95 percent. The annual low-density lipoprotein (LDL) screening rate has increased from 86 to 92 percent. The eye exam rate has increased from 67 to 75 percent. Nephropathy monitoring is at 95 percent. The percent of patients with a HBA1c greater than 9 has decreased from 30 to 22 percent and the percentage of patients with an LDL less than 100 has increased from 46 to 53 percent. Blood pressure (BP) control has improved from 30 percent with a BP less than 130/80 in 2008 to 51 percent in 2010.  
  • Fewer and shorter hospitalizations, leading to lower costs: Thirty-day hospital readmission rates declined from 20.2 percent in 2009 to 18.1 percent in 2010. The risk adjusted hospital admission rate in 2010 was just 4 percent. Hospital days per 1,000 enrollees fell from 2,762 in 2009 to 2,546 in 2011. Average hospital length of stay for program participants fell from 5.21 days in 2009 to 5 days in 2011.
  • Life choices: Another focus of work since 2009 has been to help manage end of life choices. The percentage of enrollees with advanced directives increased from 56 percent in 2008 to 67 percent in 2009. Intensive care unit days per decedent decreased from an average of 2.72 days in 2009 to 1.5 days in 2011. The percent of patients dying at home increased from 19 percent in 2009 to 37 percent in 2011.
  • Lower costs: Although members' primary care costs, including care management services, are 3 to 10 times higher than average, the alliance saves money by reducing hospital and nursing home services. In 2008, Commonwealth Care Alliance invested $3.24 million in primary care expenditures over FFS Medicare, adding 54 registered nurse/registered nurse practitioners and 22 social workers into practices that were not there before 2004 and the start of this program. As a result, hospital use in the program is 55 percent of the risk-adjusted Medicare FFS average, and the 30-day hospital readmission rate is 17.5 percent, compared with a Medicare benchmark of 19.6 percent for the entire Medicare population.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparison of costs pre- and post-implementation, as well as years of post-implementation trend data on a variety of outcomes measures.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Recruiting patient advocates to its board: The alliance recruited patient and consumer organizations to serve on its corporate board, including Health Care for All and Boston Center for Independent Living. The board was charged with making sure the Senior Care Options program provided the services its targeted population needed. At the board's direction, Commonwealth Care Alliance integrated many of Community Medical Alliance's proven care coordination, home visits, and support service strategies into the Senior Care Options plan.
  • Developing cost projections: Program leaders developed cost projections that called for significant investment in primary care services, including preventive services and screenings. Projections called for spending up to 10 times what would normally be spent on primary care services to yield dramatic reductions in costly use of ED, hospital, nursing home, and rehabilitation services (as had been achieved with the Community Medical Alliance program).
  • Recruiting primary care sites: The alliance contracted with primary care sites willing to implement the primary care team model. In making its selections, it reviewed the clinic's relationships with inpatient and specialty care providers as well as social and behavioral health services.
  • Determining payment structure to practices: The aforementioned cost projections were used in negotiating payment rates with participating practice sites. In addition, the alliance grouped its members into four categories based on medical needs, with separate payment levels developed for each category.
  • Hiring supplemental staff for clinics as needed: Because each participating primary care site had varying levels of care coordination capabilities, the alliance hired supplemental clinical staff and assigned them to provide care coordination at the clinics as needed.
  • Expanding the Senior Care Options model across Massachusetts: Over time, the alliance continues to recruit additional primary care sites to serve its Senior Care Options enrollees based on the clinic's location, experience with and volume of high-risk, elderly patients, and willingness to adopt the coordinated care delivery model.

Resources Used and Skills Needed

  • Staffing: Information provided in March 2012 indicates that the primary care team is made up of a primary care provider, a nurse practitioner or physicians assistant with geriatric experience, and a geriatric support services coordinator who has a bachelor's or master's degree or equivalent experience in geriatric social work. Each nurse practitioner cares for between 40 and 65 enrollees. The team is supported by other administrative staff at participating sites. In addition, the alliance contracts with area agencies that serve the elderly and with personal care attendants and other health care providers as needed. As of January 2011, 70 nurses/nurse practitioners and physician assistants and 25 geriatric social workers are fully integrated into the primary care practices. In addition, the program has added the role of inpatient nurse partner at two of their major hospitals.
  • Costs: As noted earlier, the program leads to lower costs by preventing use of expensive hospital, ED, and nursing home services.
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Funding Sources

Centers for Medicare and Medicaid Services; Massachusetts Office of Medicaid
Commonwealth Care Alliance receives monthly capitated (per-member) premium payments from Medicare for all Senior Care Options members and separate monthly capitated payments from Medicaid for dually eligible members; these latter payments include prescription drug coverage. The amount it receives varies according to the medical needs of the individual. In 2007, for example, the alliance received $5,200 a year for an enrollee who qualified for nursing home care but lived at home and $1,500 a year for a generally healthy Medicare enrollee. The State–Federal agreements that created the funding mechanism for the Senior Care Options plan expired in December 2008. The initiative continues under the auspices of CMS Medicare Advantage as a Special Needs Plan, with a separate contractual arrangement with the state Medicaid program.end fs

Tools and Other Resources

Master RJ. Massachusetts Medicaid and the Community Medical Alliance: a new approach to contracting and care delivery for Medicaid-eligible populations with AIDS and severe disability. Am J Manag Care. 1998;4 Suppl:SP90-8. [PubMed]

Kaiser Commission on Medicaid and the Uninsured. Dual eligibles: Medicaid's role for low-income Medicare beneficiaries. July 2005. Available at:

Brandeis University. Medicare special needs plans: lessons from dual-eligible demonstrations for CMS, States, health plans, and providers. March 2007. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)

Commonwealth Care Alliance Web site. Available at:

Adoption Considerations

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Getting Started with This Innovation

  • Establish relationships with primary care providers committed to this population: Identify primary care providers willing to engage in an intensive team approach, including orchestrating support services. Often, providers who work in neighborhood or rural health centers that have social workers on staff and whose mission is to provide comprehensive care to special needs populations are well suited to this care model.
  • Negotiate a payment structure that promotes comprehensive primary care: Negotiate a payment structure that encourages the provision of preventive care and support services and that allows the primary care site to profit financially by reducing costly hospitalizations, ED visits, and nursing home placements.
  • Negotiate agreements with hospitals and nursing homes: Negotiate payment schedules and contracts with area hospitals and nursing homes so that a continuum of care can be provided to enrollees. Make sure that providers at primary care sites know which institutions or specialists to refer patients to as needed.
  • Establish a system to monitor care, treatment outcomes, and costs: As noted, the alliance created a network-wide EMR so that patient information could be easily shared among care team members and to enable evaluation of patient outcomes, quality of care, and costs.

Sustaining This Innovation

  • Consider customizing the model to other settings: For example, the alliance is currently expanding the Senior Care Options plan into traditional, suburban primary care sites that historically have not offered care coordination services to this special needs population. As a result, it is refining staffing models, community collaboration plans, and other support services to meet the realities of this setting. For example, geriatric specialists are being "loaned" from organizations that serve seniors, and the alliance is hiring nurse practitioners to work in these clinics.

Use By Other Organizations

    There are three other Senior Care Options programs in the Commonwealth of Massachusetts.

More Information

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Contact the Innovator

Robert J. Master, MD
President and CEO, Commonwealth Care Alliance
30 Winter St. 11th Floor
Boston, MA 02108
Phone: (617) 426-0600 Ext. 225
Fax: (617) 426-3109

Innovator Disclosures

Dr. Master reported that Commonwealth Care Alliance received funding from the Commonwealth of Massachusetts in support of work related to this profile.

References/Related Articles

Porter ME, Baron JF. Commonwealth Care Alliance: elderly and disabled care. Case 708-502. Boston: Harvard Business School Publishing; April 2008. Available at:


1 Porter ME, Baron JF. Commonwealth Care Alliance: elderly and disabled care. Case 708-502. Boston: Harvard Business School Publishing; April 2008. Available at:
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: October 27, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: March 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 11, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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