Fully Integrated Care
Commonwealth Care Alliance

Fully Integrated Care

Fully Integrated Care

Fragmentation of care is one of the biggest challenges affecting people who use the traditional U.S. healthcare system today. This problem is especially difficult for those with complex health needs, when even a single gap in care can cause serious problems. 

Our approach to care is designed to overcome fragmentation of health services. We integrate every aspect of our members’ care, including preventive care, medical visits and treatment, dental care, behavioral health care, social services, and assistive devices.


The interprofessional care team

All of the care services that a member needs is coordinated by an interprofessional care team. The care team members are selected to match each member’s unique needs. A single care manager, usually a nurse practitioner or physician’s assistant, leads and manages the team. The care manager makes sure that a member gets the care they need where they need it.

Each care team may include, as needed:

  • Primary care provider
  • Nurse practitioner or physician’s assistant
  • Social worker
  • Housing specialist
  • Behavioral health specialist
  • Physical Therapist and Occupational Therapist
  • Long-term services and supports coordinator
  • Durable medical equipment coordination team
  • Clinical Support Coordinator

  • Behavioral Health Care
    Behavioral health challenges, including cognitive disorders, mood disorders, and substance use disorders, are common today throughout our communities. CCA has have developed expertise in working with adults who have these complex conditions.

    In our One Care program, 70% of members have a behavioral health condition, 15% of members have schizophrenia, and 15% of members have substance use disorders.

    We believe that the integration of behavioral health and primary care is an essential requirement of an effective healthcare system. Accordingly, in the CCA approach to care, behavioral health specialists are integrated into our care teams and play a role in clinical leadership. For individuals with significant behavioral health conditions, the care manager is a behavioral health specialist.
  • Crisis Stabilization Units
    We recognized an important gap in care for people with serious behavioral health conditions. Many of our members were going to emergency rooms in crisis, where they could spend 48 to 72 hours waiting for a bed. From the emergency room, they were often sent for inpatient care at costly psychiatric hospitals far from home.

    Our innovative solution: establishing two community Crisis Stabilization Units (CSUs) as safe and more appropriate environments for the 50% of patients who can be managed with short-term, intensive behavioral health and medical services.

    These CSUs provide a structured therapeutic setting where our clinical teams focus on maintaining member safety, improving recovery, and promoting a safe and effective return to the community.

    The results have been excellent. Eighty-six percent of the individuals in our CSUs were diverted from admission to inpatient facilities. As community and outpatient care options have increased, inpatient psychiatric admissions for our members have decreased. With CSUs proving to be an effective care option, we have slowed the rate of growth in behavioral health costs.
  • Long Term Services and Supports
    Long term services and supports (LTSS) are an essential part of how we help members keep their independence and remain living where they choose. Our care teams work directly with members to develop LTSS plans that meet their needs. The care teams authorize LTSS plans based on clinical guidelines.

    LTSS plans may include:
    • Transportation
    • Homemaking
    • Personal care assistance
    • Adult foster care
    • Companions
    • Home-delivered meals
    • Day programs

    In addition, care teams make sure that members who need LTSS care have access to appropriate resources in their communities. CCA contracts with community-based organizations such as Aging Services Access Points (ASAPs) and Independent Learning Centers (ILCs) for support services coordination. A geriatric support services coordinator (GSSC) is automatically assigned to the care team for Senior Care Options members. A long term support services coordinator (LTSC) can be added to a One Care member’s team at their request.

    LTSS coordinators from these community organizations are essential extended members of the CCA care team. They help with:
    • In-home assessments
    • Service recommendations
    • Care planning
    • Day-to-day service management
    • Knowledge of local vendors and community resources

  • Life Choices Palliative Care
    Even in a care model as integrated as ours, one major gap existed during the early years of our organization. Our enhanced primary care model did not meet the needs of the last months of a member’s life.

    To overcome this problem, we developed a new approach for providing end-of-life care. This program is called Life Choices. Its mission is to honor the choices of patients and families for palliative end-of-life care. The Life Choices program is based on these core principles:
    • End-of-life care should be a normal part of our long-term primary care model, without interruption.
    • Conversations about goals of advanced care should be promoted within the primary care relationship, and should focus on discussion, not decision
    • Because we believe in respecting patients’ wishes, patients should have the right to refuse aggressive care
    • Home-based services should provide increased support for family caregivers and allow a death at home in keeping with a patient’s wishes
    • Community partners should be included in palliative care when appropriate and beneficial

    A program as innovative as Life Choices Palliative Care requires many individual innovations. One such breakthrough is our mobile acute community care program, which sends teams of paramedics with end-of-life training to members’ homes. In many cases, this avoids the need for emergency room visits or hospital admissions.

    The data show that Life Choices delivers important benefits for our members:
    • Among SCO members who died between January 2009 and April 2017, over 55% died at home or in nursing homes rather than in a hospital
    • 64% rate of advance planning among our Senior Care Options members
    • Average number of ICU days for SCO members in their last six months of life is only 1.6 days, and declining
  • Opioid/Substance Use Disorder Treatment
    CCA’s comprehensive treatment program includes:
    • Continued engagement with members, including home visits, throughout treatment
    • Protocol-driven evaluation and use of opioids in pain control; increased interventions while reducing opioid use
    • CCA’s treatment options for members meet or exceed national standards (American Society of Addiction Medicine practice guidelines) for care of people with opioid use disorder.
    • Treatment options begin with outpatient groups and encourage full use of Medication Assisted Therapy, including methadone, buprenorphine/naloxone and injectable naltrexone. CCA provides care 24 hours/day 365 days/year by phone or in person
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