Appendix D: Spotlight: Population Health

PART I: SPOTLIGHT ON CARE COORDINATION AND CASE MANAGEMENT

Care Coordination in a Private Healthcare Organization

• Program: Fairview Partners Care Coordination

• Organization: Fairview Partners

• Population: Dual Eligible Adults Ages 65 and Older

Population at Risk

Fairview Partners (FVP), a nonprofit healthcare organization, located in the Twin Cities (Minneapolis-St. Paul, Minnesota) serves 11 counties in the surrounding metropolitan area (Fairview Health Services, 2022a). FVP primary population is adults age 65 and older who are enrolled in Medicaid health plans designed for seniors in the state of Minnesota. Members are assigned to FVP by managed care organizations with which FVP contracts to provide care coordination services. To qualify for the program, members must be dually eligible: They must qualify for both Medicare and Medicaid (Fairview Health Services, 2022b). Members must also have a primary care provider in the M Health Fairview care system, a large network of clinics and hospitals in the Twin Cities metropolitan area.

Of the approximately 4,500 members in the program, nearly 45% speak a first language other than English. FVP collaborates with several immigrant and refugee populations who have resettled in Minnesota, including the Somali, Hmong, and Karen communities, in addition to many other ethnic and cultural groups. Sixty-five percent of FVP members are female and 35% are male. Most of the population (76.5%) live in their own homes or with extended family members, whereas 14.5% live in long-term care settings and 10% live in residential care settings, such as assisted living or group homes. They reside in counties that range from rural to suburban to urban.

Healthcare conditions experienced by this population include many chronic conditions such as diabetes, cardiovascular disease, arthritis, chronic pain, cognitive impairment, memory loss, and osteoarthritis. At least half of the members have mental health diagnoses; the most common are depression and anxiety. Many experience multiple comorbid conditions and polypharmacy. Due to members’ eligibility for Medicaid, this is a low-income population; many members live in subsidized housing and receive public benefits for nutrition, housing, and supplemental aid in addition to their health insurance.

Program Overview

FVP began with a Robert Wood Johnson Foundation grant in the late 1990s to reinvent the care model in nursing homes. With the advent of federal dual-demonstration programs, FVP first began providing care coordination for adults living in long-term care facilities and in a few years’ time, the model spread to the community, which is now the largest share of program membership. FVP's vision statement reads: “We optimize the health and quality of life of older adults by providing proactive care management in the most appropriate setting” (Fairview Health Services, 2022a).

FVP now employs 54 care coordinators including both registered nurses and social workers with a 2:1 ratio and one community health worker (CHW). ...