By Marisa Scala-Foley, National Association of Area Agencies on Aging; Allison Mastriano, Direction Home Akron Canton Area Agency on Aging and Disabilities; and Joan Hatem-Roy and Christine Tardiff, Elder Services of the Merrimack Valley, Inc.
Meaningfully addressing the complex care needs of older adults and people with disabilities often requires creating new partnerships among a variety of entities that have not typically worked together. These include age-friendly communities and systems with linkages between the health care sector, public health agencies, and community-based organizations (CBOs) such as Area Agencies on Aging (AAAs), Centers for Independent Living, and other aging and disability service providers. Cross-sector partnerships can provide clinical care and targeted health-related social services while helping health care entities meet the triple aim of improving care, achieving better health outcomes, and lowering unnecessary utilization and costs. These partnerships also offer important benefits to CBOs, such as increased visibility in their communities, the ability to expand the services they offer, and more sustainable revenue streams. Most importantly, given that most health happens at home, these partnerships can help meet the holistic needs of older adults and people with disabilities.
A Rise in CBO-Health Care Entity Contracting Opportunities
Contracting between health care entities and CBOs for the provision of home- and community-based services and evidence-based health promotion programs is on the rise. With funding from The John A. Hartford Foundation and The SCAN Foundation, Scripps Gerontology Center at Miami University and the Aging and Disability Business Institute at the National Association of Area Agencies on Aging (n4a) have fielded three Request for Information surveys of aging and disability CBOs (in 2017, 2018, and 2020) to learn how many of them are contracting with health care and the nature of these partnerships. In the most recent survey, 44 percent of responding CBOs indicated that as of 2020 they participated in one or more contracts with health care entities such as health plans, health systems, accountable care organizations (ACOs), Veterans Administration Medical Centers and more — a statistically significant increase in contracting activity from 2017 (see Table 1). Their most common health care partners are Medicaid managed care plans, state Medicaid agencies, commercial or employer-sponsored health insurance, and hospitals or health systems. The most common services that CBOs provide under contract are case management/care or service coordination, evidence-based health promotion programs, transitions from hospital to home, nutrition programs, and home care (see Table 2).
Table 1. CBO Contracting, by Year
Table 2. Most Common Services Provided through Contracts
While these cross-sector partnerships can yield important benefits for health care entities, CBOs, and most importantly, the people they serve, these contracting arrangements also present challenges to the CBOs that engage in this work. CBOs responding to the 2020 survey reported on challenges experienced while establishing contracts and during the contracted work period. These challenges include lack of understanding by health care and CBOs of each other’s operations and services, as well as practical matters such as billing, timely payment, and workflows.
When it comes to developing a contract with a health care entity, the most common challenges cited by CBOs included the time it takes to develop and sign the contract and negotiating contract terms and pricing (see Table 3). For CBOs implementing contracts, top challenges were timely payment for services provided under contract, competing priorities within the health care community, denial of claims that they submitted, and sufficient referral volume of members/patients to allow the CBO to staff itself accordingly and generate revenue for the services provided. Four challenges, however, were on both lists. These (in bold in Table 3) are: (1) negotiation of price and/or contract terms; (2) staff turnover in the health care entity; (3) timely payment for contracted services; and (4) referrals and volume.
Table 3. Top 7 Contracting Challenges for CBOs with a Contract
Collaboratively Finding Solutions
While some of these issues point toward the need for better internal claims and payment systems on the part of payers to ensure timely payment for CBO services provided under contract, others require real partnership and joint work between health care organizations and CBOs. To create lasting solutions that can improve referral workflows and ensure that individuals receive the community-based services that they need, CBOs and health care must work collaboratively on a larger scale.
To address these challenges, some CBO-health care partnerships have developed Joint Operating Committees composed of representatives from both the health care entity and the CBO. These committees help develop effective referral processes and workflows, enhance communication, and address issues as they arise. Others have looked to state health information exchanges (HIEs) as a means of improving these processes and the flow of information.
Elder Services of the Merrimack Valley, Inc. (ESMV) a AAA in northeast Massachusetts, serves as a Long-Term Services and Supports Community Partner in MassHealth’s Medicaid ACO program. ESMV found that the exchange of shared health information with their ACO partners was a challenge. Working with Mass HIWay (the state’s HIE), ESMV transitioned from using fax machines to using a secure direct messaging platform to share health information with their provider partners and improve care coordination. Using a secure direct messaging platform helped ESMV streamline the process of receiving care plans from their ACO partners and allows AAA staff to track health information more easily through a single platform.
Similarly, Direction Home Akron Canton Area Agency on Aging & Disabilities in northeast Ohio incorporated CliniSync, an HIE application developed and sponsored by the Ohio Health Information Partnership, into its processes to improve access to data both for themselves and their health plan partner during the COVID-19 pandemic. With pandemic restrictions, AAA transition coaches were not permitted to conduct hospital visits, which limited their access to accurate contact and medication information as well as discharge instructions, making it difficult to reach and support members. In addition, without having information available prior to phone calls from coaches, many plan members were skeptical about speaking with them, thereby limiting their access to transition services. This disconnect caused increases in time between referral and contact by the health coach, which led to delays in administering the intervention and conducting medication reconciliation. Through a pilot project with their health plan partner, the AAA was given access to CliniSync through which coaches could obtain the necessary information for their work and increase the number of completed virtual or in person coaching visits.
These stories highlight just two examples of the work CBOs and health care entities are doing every day to overcome hurdles impeding effective cross-sector partnerships. True partnership, including access to good data, lies at the heart of the valuable work that CBOs and health care entities can accomplish together to create more holistic, person-centered systems of care that can meet the needs of older adults, people with disabilities, and caregivers.