Commonwealth Coordinated Care Program and Long Term Services and Supports Across the Lifespan

Virginia Governor’s Conference on Aging Tom Wilfong, VP, Dual Eligible Programs

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• Key to serving older adults and people with disabilities is high quality, integrated, culturally-competent service coordination for the member needing long term services and supports

• 90 percent of Anthem members surveyed state that they expect to remain in their homes, yet over 65 percent need assistance with ADLs - bathing, dressing, walking, or grooming

• Almost half need assistance with IADLs - banking, grocery shopping, managing housework and errands

Experience + Expertise

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Expand Key Partnerships

Standard • Members

and Families

• Health Plan

Expanded • AAAs and

ADRCs • Faith-

based

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Coordination isIntegration and coordination of physical health, mental health and substance use disorders with long term services and supports in the community

• Holistic approach and Member engagement are key • Access to all LTSS services through a single program,

including self-direction • Access to Coordination Support Team for individuals

with more intensive needs • Members have direct access to case managers for

individualized support needs

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Aging = TransitionsPeriodically, members may need in-patient clinical care or rehabilitation.

These experiences should not mean permanent placement which results in loss of home or total loss of independence.

A good long term services and support system means

• Preserving the ability to live in one’s own home or preferred setting in the community

• Access to wide variety of options with varying levels of support to meet emerging needs

• Flexibility and focus to transition from facility-based care to support in home and community

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Landscape of TransitionsAging is not static – members may experience a variety of transitions

• From their own home to a family member's home • From their family home to a smaller home or apartment where space is

more manageable • From a nursing facility after an health incident to home or from home to a

facility for rehab • From a hospital to home following a health incident • Support for end of life planning

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Care TransitionsKey elements of coordination during transitions: • Member’s individual plan is central • Transition planning includes family, neighbors, other care

givers as a team with the clinicians • Caregiver capacity is assessed and supported • Exchange of critical information and training for care tasks

is providing in accessible manner • Warm transfers / and check - ins • Immediate access to coordinator / manager • On-going support

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Questions?