Mathematica. Progress Together €3 Integrated Care Initiative Demonstration in Rhode Island: Beneficiary Experience Research October 2022 Danielle Whicher, Rosette Nguyen, Asta Sorenson, Alia Bayatti MMCO Dually Eligible Individuals Summary of the Rhode Island study Overview This is a summary of research results about beneficiaries' experiences with care coordination and access to health care services, home- and community-based services, and social services in the Integrated Care Initiative demonstration in Rhode Island.! The results are based on our interviews with beneficiaries who are dually eligible for full Medicare and Medicaid benefits from February to April 2022. This research was conducted through a Centers for Medicare & Medicaid Services contract for beneficiary experience research. None of these findings are indications of compliance (or lack thereof) with the three-way- contract that governs the demonstration. Methods We conducted semi-structured telephone interviews with higher-risk beneficiaries who are dually eligible for full Medicare and Medicaid benefits and enrolled in the Neighborhood Health Plan of Rhode Island (NHPRI). NHPRI is the only integrated Medicare-Medicaid Plan in Rhode Island participating in the Integrated Care Initiative demonstration. We defined higher-risk beneficiaries as those who have multiple chronic conditions, require behavioral health services, require home- and community-based services, or have some combination of these because these individuals generally have greater care coordination needs. We oversampled Hispanic and non-Hispanic African American people to understand if these smaller subpopulations of enrollees have different experiences than non-Hispanic White beneficiaries. Although this project was not exclusively implemented to assess equity between dually eligible members of differing race and ethnicity, we oversampled to explore if there are any distinct similarities or differences between groups. The study team conducted a thematic analysis of structured interview notes from 26 interviews. Based on the level of experience with care coordination reported by NHPRI beneficiaries interviewed for this study, we categorized respondents into two groups: those who spoke to care coordinators from NHPRI at least twice a year ("more connected") and those who had little to no contact with care coordinators from NHPRI ("less connected"). We developed fictitious user personas highlighting themes related to the experiences reported by more and less connected beneficiaries. User personas are a useful technique to understand beneficiaries' experience because they succinctly communicate information about beneficiary reported needs, concerns, or expectations. Results User personas We categorized 15 interviewees as "more connected" and 11 as "less connected" based on their reported level of experience with care coordination services offered by NHPRI. For each category, we created a user persona that describes a fictitious beneficiary with experiences that were typical of interviewees within that category. We defined the characteristics (gender, age, length of enrollment in NHPRI, and medical conditions) of each persona by examining the median age and length of enrollment and the most common gender and medical conditions among more connected and less connected NHPRI beneficiaries. ! Information on the Integrated Care Initiative demonstration can be found here: https://www.cms.gov/Medicare- Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/Financial Alignmentlnitiative/Rhodelsland. Mathematica® Inc. MMCO Dually Eligible Individuals Summary of the Rhode Island study Fictitious user persona for more connected beneficiaries B 1| Wi BACKGROUND e Cynthia is a 55-year-old beneficiary who has been insured by NHPRI for about 5 yvears. ® She has multiple chronic conditions. ® She requires behavioral health services and community-based long-term support services, such as a home health aide. Cynthia typically speaks to a care coordinator from NHPRI once every three months by phone. She recalls her care coordinator asking her questions about her health and needs to create a care plan. Cynthia's care coordinator provides her with resources such as information about in-network providers, available social services (transportation, food, and housing information), and covered home care services. The care coordinatoer has also arranged for needed modifications to Cynthia's home, such as a shower chair for her bathroom. Cynthia uses the resources provided by the care coordinator to find needed services. In addition to the care coordinator, Cynthia sometimes speaks to people in her community to identify other services she may need, such as food assistance. She usually arranges her own medical appointments. EXPERIENCES WITH MEDICAL PERCEPTION OF HEALTH PLAN AND COMMUNITY SERVICES Cynthia has a positive perception of While Cynthia is generally able to access primary NHPRI and the care coordinators she care providers and behavioral health professionals, speaks with. She feels that the care she once had a hard time finding specialists near coordinators listen to her needs and are her and finding reliable home care services. She is kind and helpful. She appreciates that the also able to access food banks and appreciates the care coordinators send her a written care healthy food savings card provided by NHPRI. plan but does not refer to it frequently. However, she feels that the transportation service she's tried to use has been unreliable. UNFULFILLED NEEDS Cynthia believes most of her needs have been met, but could use additional assistance finding reliable transportation services to get to medical appointments because it can be difficult to access services without transportation. In addition, while Cynthia accesses food banks and appreciates the healthy food savings card, she has additional food needs and would like additional assistance with finding affordable food. Mathematica® Inc. MMCO Dually Eligible Individuals Summary of the Rhode Island study Fictitious user persona for less connected beneficiaries [T sl s BACKGROUND ® Jesse is a 57-year-old beneficiary who has been insured by NHPRI for about 4 years. ® She has multiple chronic conditions and uses behavioral health services. ® At times, she has needed assistance around her house. When Jesse initially joined NHPRI, someone from the plan called her, but she does not recall discussing or receiving a care plan. Jesse reported that no one from NHPRI reached out to her by phone, by mail, or in person after that. She does not recall receiving any outreach fromm NHPRI following her recent hospitalization for COVID-19. Jesse would like more information about the services that NHPRI offers. She did learn about and try to use the transportation service, but she found it unreliable, so she generally relies on her family. Jesse would like to learn more about food assistance options available to her, as she sometimes has trouble with the rising cost of food. When Jesse has a question about her health plan or prescription coverage, she calls NHPRI's phone number listed on her card and someone assists her. EXPERIENCES WITH MEDICAL PERCEPTION OF HEALTH PLAN AND COMMUNITY SERVICES Despite the limited contact with a care Jesse is able to access primary care providers. coordinator, Jesse has not had significant Jesse appreciates the healthy food savings card problems with NHPRI since she generally but is unaware of other community services she does not need additional assistance may be eligible for. Jesse found that the coordinating her care. However, she would transportation service she's tried to access is have appreciated receiving outreach after unreliable. Instead, Jesse asks family and friends her hospitalization. She feels that the to drive her to appeintments when needed. member services line is helpful. UNFULFILLED NEEDS Jesse would appreciate additional help finding reliable transportation and assistance with food. She would also appreciate more frequent contact with a care coordinator after a hospitalization. Mathematica® Inc. MMCO Dually Eligible Individuals Summary of the Rhode Island study Key Findings Care coordination More connected beneficiaries More connected interviewees reported being generally satisfied with the care coordination services they received and reported speaking with a care coordinator from NHPRI at least quarterly. Care coordinators arranged for home modifications, provided lists of providers and community services, recommended home health services, and provided advice and encouragement. Less connected beneficiaries Less connected interviewees reported variable experiences with the care coordination services NHPRI provided. About half of these interviewees reported no unmet care coordination needs while the remaining interviewees expressed a need for additional support. Those who reported needing additional support would have liked more follow-up after a serious health event, help identifying necessary services to s/ '[The care coordinator] has my best interest in mind. She's involved. It's not Just coming in here and checking off boxes.. [it] feels like someone taking care of you." -More connected beneficiary W "l generally don't mind that NHPRI doesn't contact me, but it would have been nice if they reached out after my recent hospitalization to check that | was doing okay." -Less connected beneficiary meet their health goals, and more information on services NHPRI provides. Access Both more and less connected beneficiaries reported generally being able to access needed medical services, although some reported challenges finding medical specialists in their community. W "It's difficult to find a specialist. Maybe this is because of where | live." Less connected beneficiary Almost all beneficiaries who discussed needing behavioral health services said they were able to access those services. As interviewees did not speak of any experiences unique to having multiple chronic conditions, we did not draw conclusions about differences experienced by people in this higher-risk subgroup. Similarly, we also did not find major differences in beneficiary experience by race or ethnicity. Mathematica® Inc. MMCO Dually Eligible Individuals Summary of the Rhode Island study Challenges Both more and less connected beneficiaries reported challenges accessing reliable non- emergency medical transportation (NEMT) services, affordable food, or home health aide services. Several interviewees said that the NEMT vendor that NHPRI directs beneficiaries to was unreliable. The Rhode Island Executive Office of Health and Human Services selected the NEMT vendor, who contracts directly with the state.? A few interviewees said that food was unaffordable, even though NHPRI provides a monthly $25 health food savings card to purchase groceries. Some interviewees also reported accessing community services, such as local food pantries. s/ "l like to be on time for my doctors' appointments but the transportation never arrived, so | don't use them anymore. | just take the bus or have my friend take me." -Less connected beneficiary W 'INHPRI] sent me a healthy food savings card but $25 doesn''t cut it when milk is $4." -More connected beneficiary Impact of the COVID-19 public health emergency Several interviewees reported challenges finding home health aide services because of staffing shortages caused, at least in part, by the COVID-19 public health emergency. Many interviewees reported an increase in telehealth visits. No interviewees discussed challenges using telehealth platforms, although a few said they preferred in-person appointments. Possible Next Steps Based on the most significant issues beneficiaries raised in the interviews, there are some potential targets for improving care coordination and access to services, including addressing some important social determinants of health? (such as accessing food and transportation): Communication. Among beneficiaries who do not have regular contact with a care coordinator, it could help some to have additional opportunities to speak with a care coordinator about their needs and to have clear points of contact with the plan. 2 This challenge is not specific to Rhode Island; many state Medicaid agencies experience challenges providing non- emergency medical transportation. (MACPAC. "Report to Congress on Medicaid and CHIP June 2021." 2021. Available at https://www.macpac.gov/wp-content/uploads/2021/06/June-2021-Report-to-Congress-on-Medicaid- and-CHIP.pdf. Accessed May 3, 2022.) 3 Addressing social determinants of health is essential to reducing health disparities and promoting health equity for people who are dually eligible. (Long, Charron L., Stephanie M. Franklin, Angela S. Hagan, Yong Li, Jeremiah S. Rastegar, Bill Glasheen, William H. Shrank, and Brian W. Powers. "Health-Related Social Needs Among Older Adults Enrolled in Medicare Advantage." 2022. Available at: https://www.healthaffairs.org/doi/10.1377/hlthaff.2021.01547. Accessed June 22, 2022.) Mathematica® Inc. MMCO Dually Eligible Individuals Summary of the Rhode Island study Accessing food. It could help beneficiaries to have additional support from care coordinators to find local resources for free or low-cost food options and to determine their eligibility for programs such as the Supplemental Nutrition Assistance Program. Transportation. It could help beneficiaries to have additional transportation resources, such as information about public transit or local programs that provide free or low-cost transportation. Limitations of Qualitative Research Because of the qualitative nature of the research and small sample size, this study has the following limitations: Additional themes may have emerged from a broader or different sample; Beneficiaries who chose to participate in this study may have felt more strongly about their interaction with NHPRI (positively or negatively) than beneficiaries who chose not to participate, so views of nonparticipants regarding care coordination may differ; The demographics of study participants did not completely align with NHPRI enrollees as study participants tended to be younger than the average NHPRI enrollee and we intentionally oversampled beneficiaries from racial and ethnic minority groups; The approach we used for defining beneficiaries at higher-risk is different from the approach that NHPRI uses to identify people who require more intensive care coordination services, which relies on a combination of predictive risk modeling using claims data and the results of health needs assessments; and Although the study team asked questions designed to understand beneficiaries' experiences with care coordination, it may be the case that some beneficiaries did not remember receiving a call from a care coordinator or a care plan in the mail even though a NHPRI care coordinator had previously reached out. 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