Commonwealth coordinated care program and long term services and supports across the lifespan blue cross

1. 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 is
Integration 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 = Transitions
Periodically, 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 Transitions
Aging 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 Transitions
Key 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?