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The Future of Managing Chronically Ill Medicaid and Dually Eligible Patients

Lisa Feldman
October 08, 2018

Speaking on Integrated Care for High-Cost Populations on October 2nd at the Health Management Associates annual conference in Chicago, Landmark Regional President, West Rebecca Kavoussi educated attendees on the Complexivist™ model and the future of managing chronically ill Medicaid and dually eligible patients.

Hands shot in the air when Kavoussi opened with the question, “Who knows what a Hospitalist is?” But the audience drew a blank when asked to identify a Complexivist™. She went on to explain that just as hospitalists became the way we’ve come to manage increasingly complex patients in hospitals across the nation, Complexivists™ will become invaluable to managing high-cost chronically ill patients and keeping them out of the hospital.

“Our goal is for everyone to know what a Complexivist™– a provider who specializes solely in the care of medically and socially complex patients – is,” Kavoussi explained, “and for every health plan to have a Complexivist™ group in their network.”

Kavoussi went on to describe Landmark as an at-risk, fully employed provider group supported by behavioral health, addictinologists, social workers, pharmacists, dieticians and nurse care managers. In this 24/7 model, Landmark care teams treat patients where they reside – at home, assisted living, and increasingly in skilled nursing and long-term care facilities. In-home care allows Landmark to access information about patients that otherwise would not be available to PCPs or specialists, and to intervene early and often – avoiding unnecessary emergent situations.

After three years in business, growth into 13 states, and over 80,000 patients engaged, Kavoussi lists the keys to Landmark’s success. First, combining claims data with insights from the home to dynamically plan and prioritize patient contacts and visits. Second, understanding patient goals, triggers and end of life wishes, and keeping them front and center in dynamic care plans. Third, building tremendous trust so that Landmark’s patients always call Landmark first, thereby avoiding a predictable and avoidable ER visit and hospitalization. Fun fact: 97% of Landmark patients say their Landmark team helped them avoid one or more ER visits.

The audience consisted of more than 400 Medicaid business executives and policy experts. In response to the challenges of behavioral health integration and caring for complex populations raised by state agencies and Medicaid plans at the conference, Kavoussi offered a transformational vision and tactical solution –  risk-based specialists that focus exclusively on the most challenging patients. With intensifying clinical and financial expectations for Medicaid and Medicare managed-care plans, the Landmark Complexivist™ model can act as a safety valve. It allows health plans to more predictably manage risk, improve quality and drive better outcomes. And it relieves pressure on health systems trying to effectively care for the other 90-95% of their patient population.  Kavoussi was one of 46 industry-leading speakers covering topics ranging from political funding innovations to integrated care.

Originally published Oct 08, 2018 7:02 AM updated Mar 29, 2019
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