AmeriHealth Caritas Announces Next Generation Model of Care
Pioneering whole person care model will transform lives by focusing on the intersection of population health and the member experience
AmeriHealth Caritas, a national leader in Medicaid managed care and health care solutions for those most in need, operating in 15 states and the District of Columbia, announced today its new strategic initiative, the Next Generation Model of Care (NGMoC). This new model of care brings together providers, community resources, member services, caregiver support, and data analytics to deliver the promise of truly integrated, whole person care.
This new model of care will meet members where they are, and enhance their engagement with the health care system and their community. Additionally, it will apply the power of population health data to deploy services and supports to help members live healthier lives. This pioneering approach to care can help to ensure quality and meaningful results, based on individual need and preferences, to achieve better outcomes for members and, subsequently, state customers.
"Our company has taken an intense deep dive into how care is delivered to those in need and the process led us to an approach that is, at its core, a re-commitment and re-dedication to our members, and to our nation’s historic values around helping the disadvantaged and chronically ill," said AmeriHealth Caritas Chairman and CEO Paul Tufano.
"We will be without parallel in how we serve our members and state partners. As health care becomes more complex and as those most in need face increasing social barriers to achieving health and wellness, managed care organizations need to be more agile and nimble in addressing members’ specific challenges."
The cornerstone of the new model is the AmeriHealth Caritas mission: to help people — especially those most in need — get the care they need, to stay well, and to build healthy communities. The NGMoC advances the mission by:
- Focusing not only on members’ illnesses, but also on their experiences — within the health care system and their physical environment — along with supporting their caregivers;
- Applying the science of population health to deploy preventive programs for at-risk members;
- Tackling social determinants to reverse the cycle of poverty and poor health by supporting members’ needs for suitable and healthy housing, access to fresh food, transportation and job training;
- Engaging members at all potential touch points, including providers, call centers, wellness centers and caregivers;
- Based on the above member touch points, utilizing informatics to develop a complete picture of members, their needs and the outside influences that could impact their health; and,
- Providing alternatives to nursing homes or offering options to help members overcome some of the challenges of intellectual and/or developmental disabilities, so they can live more independent lives.
"The approach so often with Medicaid plans is ‘one-size-fits-all.’ However, understanding the unique needs of each individual and providing meaningful high touch engagements are key to building trust," said Dale Prestipino, Partner at PwC. "True whole person care requires a transformation from traditional managed care models to an unwavering focus on member and caregiver needs using a personalized mix of social and clinical programs that produce a material difference —an incredibly daunting exercise for many managed care providers—so compassion and data can foster the highest quality outcomes. While most companies are attempting to reach this goal by implementing pieces of this approach, AmeriHealth Caritas is the first Medicaid managed care organization to take a deliberately holistic approach that will drive improved health outcomes."
AmeriHealth Caritas Forms Health Services and Health Markets Divisions
To operationalize the NGMoC, a Health Services division was created to coordinate medical and support services for members and their caregivers. It fully integrates clinical and social services, bringing together all the functions that manage a member’s care. The division is being led by Executive Vice President, Marilyn Eckley, who was formerly the company’s Senior Vice President of Enterprise Operations.
"With the Next Generation Model of Care, we are truly aligning and integrating all the services that directly and indirectly impact our members, which is unique in our industry. We are now positioned to continue our leadership in developing best-in-class solutions and capabilities that support health outcomes for our members and enhance our partnerships with providers," said Eckley.
Additionally, a complementary Health Markets division will drive growth, strengthen AmeriHealth Caritas’ existing businesses, and expand its product portfolio. The division will be led by Executive Vice President, Steve Bohner, who was formerly the company’s Chief Financial Officer.
Health Markets will include local lines of business across the country, as well as Marketing, Business, and Product Development, and the existing business lines around Medicare, Long Term Services and Supports (LTSS), PerformCare, and PerformRx. Health Markets will also roll out a business line devoted to enhancing the lives of members with intellectual and developmental disabilities, called ID/DD Solutions.
"I have spent over 25 years at AmeriHealth Caritas, and I have never been more energized or more optimistic about what the future holds for our members, customers and associates. The Next Generation Model of Care will have a customer-focused approach that forges strong relationships with our members, providers and state customers," said Bohner.
"With the strong leadership team in place and a renewed energy and focus, this new model of care is truly a defining moment in the AmeriHealth Caritas story," said Tufano.
Amber: An AmeriHealth Caritas Story
Amber is a single mother of five children living homelessly in a food desert section of Washington, D.C. To make things worse, Amber was admitted to the hospital only to be diagnosed with stage 4 ovarian cancer.
After connecting with Amber at the hospital, our associates were able to help her and her children: 1) secure housing; 2) gain access to healthy foods; 3) obtain a cell phone; 4) schedule transportation to her medical appointments; and 5) apply for interim-disability assistance.
Regular check-ins with Amber help her keep track of appointments and prescriptions.
With the Next Generation Model of Care
Based on population health data that identifies patterns of health determinants, AmeriHealth Caritas opens a Wellness Center in Amber's community to help local residents engage the health care and social services system more easily and effectively. There, they can access services that address social determinants (housing, transportation and healthy foods, etc.) and participate in programs that address health needs specific to the area, like smoking cessation and nutritional education, to improve the overall health of the community.
Wellness Centers also perform Health Risk Assessments (HRA) that allow AmeriHealth Caritas to see emerging health on an individual and community basis, allowing the company to deploy care coordinators or partners to assist members who are vulnerable to certain health risks, and improve wellness.
Additionally, a care coordinator helps to:
- Identify the right pediatrician for Amber's children, looking into preferred language, office hours, and the location to make sure there was easy access to bus transportation.
- Engage Amber every month, in person and over the phone, to see if she needs any help with her medical or social services as she navigates the health system.
- Coordinate services with Amber's PCP to prevent gaps in care and improve her chances of recovering from cancer.
- Contribute data and observations that can continuously improve the level of service for members like Amber.