Developing a Coordinated LTSS Ecosystem to Support Whole-Person Care

Published October 29, 2021

The individuals who use Long Term Services and Supports (LTSS) are often some of the most vulnerable, high-cost patients in the health care system. This means it is especially critical that health plans are supported in providing these services in a coordinated, patient-centric way to optimize outcomes.

During AHIP’s National Conference on Medicare, Medicaid, Dual Eligibles Online, Dr. AnneBeth Litt, Medicaid Medical Director of CareCentrix, Kristin Murphy, Senior Director of Partnerships and Special Projects for ADvancing States Inc., and Nicole Sunder, Director of Health Plan Solution Design of Collective Medical, discussed how plans can improve whole-person care through a connected LTSS ecosystem.

The webinar discussed three critical components of effective LTSS programs: predictive analytics, insight sharing, and outcome assessment. These components are proactively involved in engaging home and community-based services (HCBS) to customize and reduce excess personal care hours.

Robust Predictive Analytics

Effectively serving the LTSS population starts with identifying the individuals who can benefit the most from this type of care. CareCentrix utilizes robust proprietary predictive analytics that allow plans to identify members who are at high and rising risk for emergency department use or acute hospital admission, so that health plans can provide services to those most in need. This can prevent unnecessary readmissions, reduce the total cost of care, and improve quality of care for the individual.

These real-time analytics act as a guide not only in identifying members, but throughout every step of the care journey. This allows for a holistic, personalized care plan to develop, which ensures HCBS alternatives are being utilized to optimize personal care hours.

CareCentrix Care Navigator

The CareCentrix Care Navigator serves as a dedicated point of contact, for Health Plan Care Managers. Leveraging our analytics, and personalized care recommendations, the Care Navigators take the lead on collaborating the exchange of information for care coordination.

The Care Navigator also monitors the utilization of services and supports to ensure the care being delivered aligns with the individual’s needs, eliminating waste and improving the patient experience.

Comprehensive Home Solutions

As individuals who can benefit from LTSS are identified and the specific services they need are determined, CareCentrix uses analytics to direct health plan members to the most appropriate site of care, with an emphasis on the home. CareCentrix then helps individuals get the services they need to stay at home, manage their chronic conditions, and avoid unnecessary readmissions.

These home-based services are enabled in large part by digital tools, like remote patient monitoring, which allows caretakers to easily track an individual’s progress and recommend care plan enhancements. These tools also account for non-clinical elements of an individual’s care plan that can contribute to overall well-being.

By leveraging whole-person predictive analytics and technology to support care navigation and home-based services, CareCentrix supports the growing number of payors caring for LTSS populations, helping them identify the right people and services, share insights, and improve outcomes.

Download the  CareCentrix LTSS brochure

Want to optimize your LTSS strategy and better support your members? Click here to learn how CareCentrix can help.


Additional Reading

Are you interested in learning more about the topic? Here are some resources we suggest: