Improving Health Outcomes for Individuals with Complex Needs

Collaborative care approaches are critical in supporting individuals with complex needs to live their best life.

Complex populations, comprise five percent of the Medicaid enrollment and include individuals with considerable social, behavioral, medical needs and unique capabilities who receive support from various programs, providers and agencies in order to remain safe and well in their communities.

Medicaid programs serving individuals with complex needs have largely remained fee-for-service and account for approximately 50% of spending. As a result, coordination of care has been significantly fragmented, particularly for those dually enrolled in Medicare or multi-system involvement, such as the child welfare or the legal system.

Inadequate care coordination across multiple systems of care, physical and behavioral health and socially necessary services, places these individuals at risk of experiencing a crisis, emergency or inpatient treatment, or institutionalization. As a result, individuals with complex needs experience poorer health outcomes and increased costs to the health care system.

CareSource focuses on supporting individuals in complex populations with significant medical, behavioral and social needs in all of our markets.

“CareSource is a leader in managed care for individuals with complex needs,” said Josh Boynton, Senior Vice President of Complex Health Solutions at CareSource. “We support our members as they achieve their goals and dreams, partner with families and stakeholders to create inclusive communities all while coordinated access to high quality medical and non-medical care.”

CareSource’s Complex Managed Care Model is focused on four key foundational elements:

1. Member voice and choice: The member self-directs a care plan that outlines the member's life goals, functional strengths and identifies the services and natural supports necessary to help them live well in communities.
2. Medical and non-medical services: Non-medical services comprise the majority of the cost of enabling members with complex needs to live well in their community. This includes services such as independent living and employment, which provide members with the skills and support to live, work and play in the community as they choose.
3. Caregiver support: Caregivers play a significant role in providing natural supports to individuals with complex needs. Complex managed care must ensure the health and wellness needs of caregivers are met too.
4. Quality strategy: Quality strategies for individuals with complex needs incorporate quality of life measures as well as Healthcare Effectiveness Data and Information Set (HEDIS) metrics. Quality improvement processes help to ensure the programs and supports are meeting the needs of the members and continuously assess the effectiveness of interventions.

Through coordination and collaboration with outside organizations and agencies, CareSource continues to work together to better address health disparities, ensure members have access to the entire spectrum of services and supports and substantially improve their overall health and wellness. Having a self-directed, person and family-centered approach enables CareSource to collaboratively develop plans with members and their circles of support based on individualized goals and functional strengths. Furthermore, understanding the root of complex needs is layered in the context of inequality helps us improve community integration for complex populations.