This is the second article in a two-part series exploring Medicare Advantage special needs plans (SNP).
Evercare rolled out a Medicare Advantage SNP in January designed specifically for people with chronic disease and dementia.
Medicare has agreed to pay for services that help the caregivers of these patients, not the patients themselves. The program also includes direct collaboration with Banner Alzheimer’s Institute in Phoenix, which helps families dealing with dementia.
“In Arizona, we are taking care of many patients with dementia and chronic disease,” says Ana Fuentevilla, MD, medical director at Evercare’s Arizona region. “Before we initiated this program, there was a huge burden for caregivers that was not being attended to and that had a direct impact on our ability to provide optimal care for the patients.”
Fuentevilla and her colleagues sought the advice of the Banner Alzheimer’s Institute in developing a specific benefits package that would meet the needs of these caregivers. Within three months after proposing the plan to CMS, the government approved this first SNP for Alzheimer’s disease, she says.
The program targets all stages of the disease, including late-stage dementia when DM strategies are most difficult to implement because of the beneficiary’s cognitive impairment.
Key elements of the program are education for caregivers and members, care manager coordination, special prescription drug coverage for dementiarelated therapies, free enrollment in the Alzheimer’s Association Safe Return program (a program that helps families find a loved one who wandered from home and got lost), and emergency respite services that provide caregivers with a break so they can address their own healthcare needs. Another added benefit to caregivers is free transportation for up to 10 one-way plan-approved trips per year.
“We looked at the traditional benefit package for a special needs plan and added a couple of additional benefits for this population,” says Fuentevilla. For example, the drug benefit includes the memory drug Aricept on the formulary, but it also includes it in a lower tier so that the out-of-pocket copay expense for families is less, she says.
Professional care managers lead team
“Our care managers are essential to helping members and families navigate the maze of the healthcare system,” says Fuentevilla. Care management is very intensive, with an assessment scheduled with the member and family immediately after enrollment in the SNP program.
“This is a two- to three-hour meeting in which we help caregivers assess the member’s current status and help the families understand and anticipate decline,” says Julie Keys, LMSW, clinical manager of the Alzheimer’s disease special needs program. “Our care team, unlike other disease management care teams for Medicare patients, must be experts in dementia care.” Each care manager receives specialized training from the Banner Institute.
“The goal of our care managers is to be both preventive and proactive,” Keys says.
She cites an example of a patient who has started to exhibit behavior changes that include combativeness or paranoia. “These are two common situations with dementia patients,” she says. “We prepare the caregiver through education that explains what is happening to make the patient act this way and strategies for reacting to and managing it.”
The in-home meeting and subsequent visits (as needed by the caregiver) allow the care manager to identify triggers in the home that might lead to difficult-to-manage behavior. For example, if the person with dementia is talking to imagined people, the solution may be as easy as taking down all mirrors and pictures in the house, says Keys. The eight-week educational program for families allows care managers to share techniques they have learned at Banner with caregivers.
Membership in this SNP also provides families and patients with the opportunity to visit with a dementia specialist at Banner to evaluate conditions and develop a care plan and to participate in clinical trials if they are interested.
“It is really important for the patient’s primary care physician to understand that this program is not a replacement but rather a collaborator,” says Fuentevilla. “Our care managers work closely with the physician, particularly in managing the member’s other chronic illnesses.”
Fuentevilla says Medicare beneficiaries in this program will undoubtedly have other chronic diseases, such as diabetes and CHF, that must be managed as part of an overall chronic care plan. “What we are doing with the Alzheimer’s program is incorporating these services into the chronic disease model,” she says.