Adapting a Model of Integrated and In-Home Care to Serve Medicaid Patients with Multiple Chronic Conditions

California’s Medicaid program, Medi-Cal, is the largest state Medicaid program in the nation and the main source of coverage for low-income children, adults, and people with disabilities. It also provides wraparound coverage for many elderly Medicare beneficiaries. This project, funded by the California Health Care Foundation, evaluated an innovative care delivery model built on a partnership between Landmark Health, the Inland Empire Health Plan, and the Health Plan of San Mateo to deliver coordinated services to eligible Medi-Cal managed care members with multiple medical and behavioral health needs. These individuals are among the least well cared for in California’s safety net population as well as the most expensive. Under the model, Landmark delivers intensive care for members with five or more chronic conditions. Interdisciplinary care teams provide in-home medical services as well as 24/7 crisis management services in addition to coordinating health and social services. The goal is to enhance delivery and coordination of care, improve quality of life, and generate aggregate savings by improving medical management, thus reducing costly events such as emergency care and hospitalizations.  

The model has had some success within a Medicare Advantage population outside of California. However, adapting the model to the Medicaid population represents a new challenge. We found that Landmark’s home-based intensive care model in the Inland Empire Health Plan and the Health Plan of San Mateo settings accomplished many of its goals by changing patterns of health care use for engaged members. The model was associated with statistically significant decreases in ED visits and inpatient stays with an associated behavioral health diagnosis, increases in primary care visits, and increased rates of follow-up after discharge from inpatient and skilled nursing facility stays. Together with evidence from other programs, our findings support the idea that providing coordinated home-based services that include a behavioral health component and address patients’ unmet social needs can meaningfully reduce acute care spending. Supported by a growing body of evidence, home-based care models have established themselves as an important approach to improving the quality and efficiency of care for patients with complex health care needs across the spectrum of healthcare payers.