Solved: Please read the following Public Policy Institute Report for the AARP on the evaluation

Please read the following Public Policy Institute Report for the AARP on the evaluation of S/HMOs. Based on the following summary do you find any special worthwhile need or benefit from Social Health Maintenance Organization s(S/HMO)? Please post your opinion before the end of the Module.

Potentially relevant research findings emerged from evaluations of the Social Health Maintenance Organization (S/HMO) demonstration projects. These projects, which have been ongoing at various sites since 1985, provide acute and long-term care to low-income elderly persons. The S/HMOs are reimbursed on a capitated basis, from a combination of funding sources, especially Medicare and Medicaid. The operational aspects of S/HMO programs differ across the projects, and the programs have each evolved separately over the years. Care management has figured prominently at virtually every site:

The S/HMOs have used care management approaches to assess chronic care needs and authorize services for enrollees.
Care managers have assisted enrollees in obtaining non-covered services and benefits, such as Social Security entitlements, legal aid, and housing.

An early evaluation report observed that “the case managers have been able to monitor and maximize benefits with considerable success.” But the evaluators found variability “in the extent to which the acute and long-term services had been integrated to provide an effectively coordinated continuum of care for impaired elderly.” Subsequently, other reviewers of early S/HMO results have called for better links between S/HMO care management and acute and post-acute care. Two themes emerge from specific suggestions: first, there are opportunities to improve policies and processes for physician presence and involvement in post-acute care planning; and second, more activities should be directed at streamlining assessment and coordinating Medicare skilled care with related “community care benefits.”

The data on care management costs are relatively positive in terms of total S/HMO costs, which are financed by Medicaid as well as Medicare. The care management function is reflected as a modest administrative cost, or even as a revenue center to the extent that needs assessments result in Medicaid eligibility determinations. However, there is no documentation of overall Medicare savings attributable to S/HMO case management activities. Further, since the S/HMO demonstrations are studies in capitated reimbursement, cost data are not particularly useful in the context of fee-for-service Medicare.

HCFA’s research of care management in Medicare and the S/HMOs is generally inconclusive. However, the findings do point in specific directions for further work. First, the weight of the available evidence indicates that Medicare care management holds the most promise when the activities are highly focused, especially if centered on beneficiaries with specified conditions, such as congestive heart failure. Second, while care management in post-acute care may not reduce Medicare costs, the patients nonetheless benefit from efforts of care managers to maximize their care options.

PROVIDE A RESPONSE AND REMARKS TO THIS STUDENTS DISCUSSION POST BELOW, BASED ON YOUR UNDERSTANDING:

Students reponse:

I think it is definitely worthwhile exploring the need and benefits from a Social Health Maintenance Organization (S/HMO), or variations of its previous version in order to integrate needed health related services into a single healthcare delivery system.

The S/HMO began in the early 1980’s, through the enrollment of children with special health care needs and for disabled adults and the chronic illness. This service is also known as PACE, Programs for the All-inclusive Care for the Elderly. The benefits include case management services in order to develop and carry out thorough assessments of patient and family needs, individualized plans of care, arrangement for community services, and ongoing monitoring. Some additional benefits include nursing home, home health, personal care assistance, transportation, hospice, durable medical equipment, and prescription drugs, just to name a few. Another added benefit is that it was designed to improve access to appropriate services through coordination and transition of care. There is a need for long-term care programs as well as the demand for community long-term care services in order to improve the quality of life for this vulnerable population.

While the results were mixed, I believe with the shift of healthcare moving towards population health management, there is a need for this model for centralized coordination of care, which can potentially reduce the fragmented and often duplication of care, which will likely result in greater efficiencies.