A 72-year-old woman is dually eligible for Medicaid and Medicare. She is receiving in-home care and has started exhibiting symptoms of a urinary tract infection (UTI). Her symptoms get worse and is taken to the emergency room with abdominal pain, weakness and confusion. After a short stay in the hospital, she is discharged and recommended for home health to regain her strength.

Her caregiver is new and does not know her history with home care. Her former in-home care caregiver is unaware of the recent hospital stay and additional services needed. These home care and home health services may not be happening simultaneously due to insurance. What important health needs and information are slipping through the cracks?

What if the symptoms of her UTI were caught sooner and a home health episode had been implemented? She could have avoided the ER and hospital stay. What if she could maintain her caregivers who know her and her needs? Is there a way for all of these needs to be addressed seamlessly while avoiding the ER visit and maintaining continuity of care?

These types of scenarios happen daily for individuals in our community. How do we move them through the continuum of care without losing consistency?

The intersection of Medicare and Medicaid for dual eligibles

As if the American healthcare landscape was not complex enough, a population representing particularly unique healthcare needs, and in need of unique solutions to meet them, is growing: dual eligibles.

Dually eligibles are generally described as low-income and enrolled in both Medicare and Medicaid. While Medicare is a federal program available to eligible citizens and legal residents once they reach 65 or are disabled, Medicaid is administered at the state level and funded jointly by the federal government and state. Medicaid is available to low-income individuals with a demonstrated need, regardless of age. Medicare pays first when a dual eligible receives Medicare-covered services, and Medicaid pays last, after Medicare and other health insurance.[1]

As a general rule, Medicare does not pay for custodial care, if it is the only care needed. If you need assistance with activities of daily living like bathing, dressing, using the bathroom, etc. Medicaid will pay if you are eligible and in accordance with state-specific programs. Medicare pays for acute care needs. This includes nursing and therapy needed to recover from an illness or hospitalization. The handoff, or lack of one, between these, is a perfect example of how our healthcare delivery system fails to coordinate care and why for dual-eligible individuals the issue is particularly acute.

Coordinating care for dual-eligible clients

Recognizing the need to solve this lack of coordinated care for this population is not new. In 2010, the Affordable Care Act made it a requirement that certain Medicare Advantage plans (those that focus on the dually eligible) contract directly with state Medicaid agencies so they can – among other things – coordinate care. Except for instances where states have implemented fully integrated Medicare/Medicaid health plans, coordination is limited. Even where fully integrated Medicare/Medicaid plans have been implemented, only around 7% who qualify have enrolled.

The challenge to solve for this is only growing. The number of dual eligibles is on the rise. They now include more than 12 million Americans, representing approximately 3% of the US population.[2] Factor in that the number of people over 65 will be around 100 million by 2060, and the potential for a crisis becomes apparent.[3]

Missed opportunities to coordinate care can result in healthcare complications for anyone. Not only is that risk amplified for dually eligible individuals because of their higher health risk status, but the dual payment system between Medicaid and Medicare also increases the likelihood that opportunities to coordinate care are missed. As a result, dually eligible individuals are three times more likely than non-duals enrolled in Medicare to need assistance with activities of daily living and 4x more likely to be food-insecure. They are two times more likely to use the ER and need home health services, and 1.5 times more likely to be hospitalized.[4] This results in worse health outcomes, increased difficulty accessing care and higher overall spending.[5]

Improving how we coordinate care offers benefits including improved healthcare outcomes, reduced costs for both programs, higher client satisfaction and consistency of care. It enhances communication across various healthcare settings and not only addresses immediate medical issues but broader societal factors that impact an individual’s health.

Focus on coordinating care

PurposeCare offers a promising solution to the challenges faced by dual-eligibles by emphasizing the importance of coordinating care. Integrating coordinated home care and home healthcare services enhances the quality of life for a healthcare population that has been neglected, or offered services and benefits that are inaccessible. An approach that coordinates and delivers the most impactful services ensures that dual eligibles and their families seamlessly transition through different levels of care.

Caregivers are trained to spot changes of condition in their clients and refer them internally to the nursing team to ensure timely intervention and triage and, where appropriate, assess for home healthcare. We do this by recognizing and making use of arguably one of the most under-appreciated and under-utilized resources – the caregiver. That can be a home health aide or personal care aide. It can also be a family member.

Educating, supporting and empowering the caregiver to identify changes in condition as soon observed and providing them with the support to coordinate care helps to reduce the total cost of care, increase the quality of care and the satisfaction of our clients. When our clients require skilled nursing or therapy in the home, we are able to keep their care within the PurposeCare team and maintain continuity of care and consistency with caregivers, which results in better outcomes.

Targeted support for dual eligibles addresses a crucial gap in the current healthcare system. By concentrating on a coordinated home care strategy, PurposeCare is continually refining and expanding services that increase visibility into an inefficient and unhealthy status quo for vulnerable populations. Simultaneously, it increases access to the full range of care and services that dual eligibles require and, in fact, deserve.

Rich Keller is CEO of PurposeCare, a home care and home health firm in four states. PurposeCare also provides care coordination and assistance, and home safety assessments.

[1] https://www.medicaidplanningassistance.org/dual-eligibility-medicare-medicaid/

[2] https://www.healthaffairs.org/topic/1100

[3] https://www.whitehouse.gov/briefing-room/presidential-actions/2023/04/18/executive-order-on-increasing-access-to-high-quality-care-and-supporting-caregivers/

[4] https://atiadvisory.com/wp-content/uploads/2022/06/A-Profile-of-Medicare-Medicaid-Dual-Beneficiaries.pdf

[5] https://homehealthcarenews.com/2022/06/report-finds-dual-eligible-individuals-use-home-health-care-at-higher-rates/