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Service Delivery Innovation Profile

Health Plan–Financed, Nurse-Led Care Coordination Improves Quality of Care and Reduces Costs for Latinos With Chronic Illnesses and Disabilities

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With funding from a per-capita payment system, nurses at Brightwood Health Center, a community-based primary care clinic, provide culturally competent care coordination to predominantly Latino patients with chronic illnesses and disabilities. Through this model, Medicaid enrollees identified as having special health care needs receive enhanced primary care, onsite mental health and addiction services, care coordination, and support services based on their levels of need. The program has improved the provision of recommended care, reduced health care costs, and enhanced self-management capabilities.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of adherence to recommended-care processes and per-member-per-month health expenditures, along with post-implementation feedback from program participants.
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Developing Organizations

Brightwood Health Center
Springfield, MAend do

Date First Implemented

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Patient Population

Vulnerable Populations > Disabled (physically); Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Insurance Status > Medicaidend pp

Problem Addressed

Low-income, ethnic minorities are poorly served by the Nation's health care system, particularly those with disabilities and chronic illnesses and who do not speak English. Typical problems include communication barriers (driven in part by a shortage of culturally and linguistically competent providers) and lack of access to appropriate care and information.
  • Poorly served: The National Healthcare Disparities Report found that low-income, ethnic minorities are more likely to be diagnosed with late-stage colorectal cancer than are whites, less likely to receive recommended diabetic services, and more likely to be hospitalized for diabetes and related complications. When hospitalized, minorities are less likely to receive optimal care for acute myocardial infarction (heart attack) and pneumonia. African Americans also have higher rates of avoidable hospital admissions.1
  • Additional challenges for Latinos and those with disabilities: Latinos are more likely to report unmet health care needs and poor communication with their physicians and less likely to receive preventive screening and treatment.1 Latinos also may have more difficulty than other ethnic groups in accessing health care information, including information on prescription drugs. For those with disabilities, barriers to high-quality care include lack of physical access to care, communication difficulties, and learning disabilities or cognitive problems.2

What They Did

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Description of the Innovative Activity

The Brightwood Health Center offers a culturally competent care-management and coordination program serving low-income, Latino adults with disabilities and chronic diseases. This model uses small health care teams, led by a nurse care manager/coordinator, to provide comprehensive medical and psychosocial services to meet the needs of individual patients. The health center receives a per-patient (capitated) payment for providing these care-coordination services. Highlights of the program include the following:
  • Upfront screening to identify and enroll those at risk: Staff screen patients to determine individual risk factors and the need for care coordination, behavioral health services, preventive care, or intensive care management. They screen all individuals receiving long-term unemployment benefits, disability benefits through Social Security's Supplemental Security Income program, and Temporary Assistance for Needy Families under the Medicaid program; screening indicates that many of these individuals have disabilities or chronic illnesses.
  • Maximizing benefits for Medicaid beneficiaries: During enrollment, case managers ensure that individuals are enrolled in Medicaid through the eligibility category that maximizes their benefits.
    • Provision of convenient, coordinated, culturally competent services: Brightwood provides comprehensive, culturally competent care-management services within its community-based facility, including coordinating mental and behavioral health services and addiction counseling and treatment. Key elements of these services are described below:
      • Culturally competent care: Nurses and providers are culturally and linguistically adept at managing and coordinating care in the local community. Nearly all of them speak both Spanish and English and know the community in which they work.
      • Customized care plans and care teams: After initially assessing the patient, the nurse and primary care physician work together to develop a care plan. For most patients, this plan calls for the formation of a care team that works with the primary care physician. The team typically includes the designated care coordinator and, as needed, registered nurses (RNs), nurse practitioners, mental health and addiction counselors, and support service staff.
      • Empowered care coordinator with small case loads, available 24 hours a day: The nurse care coordinator has the authority to directly advocate for patients, link them to support groups and community services, and order equipment and medications in partnership with the supervising physician. For example, if a patient needs a hospital-style bed, the nurse has the authority to order the bed directly, without having to obtain other approvals. The nurse can also modify medication plans with physician oversight and monitor patient response to treatment. A 24-hour-a-day, 7-day-a-week call system relays patients' calls directly to their care coordinator. Typically, care managers have caseloads of roughly 45 complicated or 80 less complicated patients. These low ratios allow nurses to coordinate and monitor each patient's care plans; follow up with patients to ensure adherence to medications and preventive health appointments; facilitate referral to support groups; and follow up after emergency department (ED), hospital, or substance abuse admissions.
      • Intensive care management as needed: High-risk patients receive more intensive care-management services, including a dedicated 24-hour call system, home visits by a nurse practitioner, and accompaniment by a nurse to specialty medical appointments.

    Context of the Innovation

    The Brightwood Health Center serves a community of about 10,000 in Springfield, MA, with most patients being of Puerto Rican heritage. Just under one-half of the population served is 18 years or younger, and 11 percent are older than 60. The community is among the poorest in the state and has the lowest educational attainment among all Springfield communities (only half of residents had completed high school). The community has long been characterized by high rates of teen births, chronic disease, infant mortality, and incarceration. In 2008, only half of 2-year-olds had been fully immunized, and the community was at the center of the HIV epidemic in Greater Springfield, with an infection rate five times higher than the state average. To address these issues, leaders at the Brightwood Health Center joined forces with Neighborhood Health Plan, a Medicaid managed-care organization, to design and implement an alternative structure of care for patients with disabilities and chronic illnesses. When Neighborhood Health Plan discontinued funding, Brightwood partnered with Commonwealth Care Alliance, a not-for-profit care-delivery system that provides integrated health care and related social support services. It offered medical and social services for people with complex needs covered under Medicaid and for those dually eligible for both Medicaid and Medicare, including older adults; individuals with serious physical, cognitive, or chronic mental illness; and children with special needs.

    Did It Work?

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    The program has improved the provision of recommended-care processes, reduced health care costs, and enhanced self-management capabilities.
    • Greater provision of recommended-care processes: Among those enrolled in the program continuously from 2000 to 2007, adherence to recommended-care processes increased significantly, as outlined below (all comparisons are between the second quarter of 2004 and the last quarter of 2007):
      • Diabetes care: The percentage of patients with diabetes who had their hemoglobin A1c (long-term average blood sugar) levels checked in the preceding 6 months rose from 71 to 100 percent.
      • HIV/AIDS care: The percentage of HIV/AIDS patients who had their CD4 and viral loads tested every 3 months increased from 87 to 94 percent.
      • Cancer screening: The percentage of women over the age of 18 who had a Pap smear to screen for cervical cancer within the past year increased from 50 to 65 percent. The percentage of women aged 40 and older who had a mammogram in the past 12 to 15 months increased from 78 to 89 percent.
    • Maximization of Medicaid eligibility benefits: Case managers have changed Medicaid eligibility categories for nearly a quarter of enrollees to ensure that they are enrolled in the category that maximizes their benefits.
    • Lower costs: Between 1999 and 2002, the average expenditures for those enrolled in the program were $204 per member per month lower than for similar patients in the fee-for-service program, even after accounting for the $86-per-member-per-month cost of program services. These reductions stemmed primarily from lower inpatient and outpatient expenses for high-risk enrollees, which were offset in part by higher expenditures for low-risk enrollees, as detailed below:
      • Higher costs for low-risk enrollees: Before the intervention, the majority of enrollees (63 percent) incurred costs less than $500 per member per month, suggesting low levels of risk. During the intervention, costs for this same group of individuals increased significantly (to about $775 per member per month), likely due to improved access to needed services.
      • Stable costs for moderate-risk enrollees: Costs for moderate-risk enrollees (the 24 percent of enrollees with per-member-per-month costs between $500 and $2,000 before the program began) stayed fairly stable, although use of hospital-based services declined for all enrollees with pre-enrollment costs above $500 per month.
      • Significant declines for high-risk enrollees: For the 13 percent of patients with pre-enrollment costs exceeding $2,000 per member per month, significant reductions in monthly medical costs occurred after enrollment, with average costs falling from roughly $9,400 to $2,500.
      • Increases in less costly, nonhospital medical expenses: Nonhospital costs, including physician services, transportation, pharmacy, behavioral health, and other medical services, increased as a result of the program, primarily due to participants' enhanced access to these needed services. ED costs also increased, although ED utilization fell slightly, from 0.109 to 0.097 visits per member per month.
    • Enhanced self-management capabilities: Before enrolling in the program, most participants found managing their health to be an overwhelming task. After participating in the program, these same participants reported that the bilingual care managers and providers improved their care-seeking behaviors, their willingness to make and attend medical appointments, and their understanding of their health conditions and treatments.

    Evidence Rating (What is this?)

    Moderate: The evidence consists of pre- and post-implementation comparisons of adherence to recommended-care processes and per-member-per-month health expenditures, along with post-implementation feedback from program participants.

    How They Did It

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    Planning and Development Process

    Key steps included the following:
    • Identifying barriers to care: Brightwood providers documented that many patients with chronic illnesses and disabilities experienced frequent and preventable complications from asthma, diabetes, hypertension, cardiovascular disease, and depression. Clinicians identified several important barriers to care for these patients, including the difficulty of identifying people at risk of complications before they became ill, insufficient time to build relationships with patients to help them understand their health and stay involved in their care, and a severe shortage of culturally and linguistically competent mental health and substance abuse treatment providers.
    • Partnering with key Medicaid managed-care organization: Brightwood was one of the primary care providers in the Neighborhood Health Plan network. However, most of Brightwood's patients were not enrolled in Neighborhood Health Plan and instead remained in the Medicaid primary care case-management program, a fee-for-service system with limited care coordination. Brightwood leaders met with Neighborhood Health Plan to design and implement an alternative structure of care that promoted care management and a variety of onsite services for their patients with disabilities and chronic illnesses.
    • Reallocating funds to support program: Negotiations led to agreement by Neighborhood Health Plan to reallocate funds from its capitated payment from Medicaid to cover the costs of program services. The plan's leaders believed that this reallocation would prove to be at least cost neutral (due to savings in acute-care expenses) and also improve member health and quality of life.
    • Hiring culturally adept support and psychosocial staff: Brightwood hired nurses, nurse practitioners, mental health and addiction counselors, and support service staff who spoke Spanish, understood the patient population, and could work as part of a multidisciplinary clinical team.
    • Creating criteria to target high-risk patients: The leaders developed criteria to quickly identify patients who needed the most intense care-management services.
    • Identifying opportunities to improve care process: Brightwood closely examined and monitored its patient-care processes and metrics to identify areas for potential improvement, such as investing in staff training, appointment tracking, and disease-management software to track patient care, followups, and referrals.

    Resources Used and Skills Needed

    • Staffing: A team of seven bilingual nurse practitioners and five RNs serves as the designated care coordinators for 900 patients, not all of whom require intense care coordination. For the delivery of services, different team-staffing models are used, depending on the needs of individual patients, with all team members being bilingual. For example, the team serving 50 homebound seniors consists of a primary care physician, nurse practitioner, medical assistant, and half-time social worker. The team for nonhomebound seniors consists of a physician, RN, and medical assistant. Patients with HIV or critical health needs have a team composed of a nurse practitioner, medical assistant, administrative assistant, and part-time mental health worker. On average, each team serves 120 patients with multiple health needs.
    • Costs: Brightwood initially received an additional $86 per member per month to cover the costs associated with the care-coordination program. Care-coordination payments for the most critically ill patients, such as those with HIV or homebound seniors, were higher, sometimes as much as $300 a month. These payments covered the costs of clinical and support staff salaries, supervision, and program administration, with separate payments provided for medical services. Medicaid eventually replaced the capitated funding model for care coordination through Neighborhood Health Plan with a new funding model through Commonwealth Care Alliance that relies on a fee-for-service payment mechanism. When this transition occurred, Commonwealth Care Alliance began directly employing the care coordinators, who continued to work directly with Brightwood's health care teams.
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    Funding Sources

    Neighborhood Health Plan; Commonwealth Care Alliance; Health New England
    In 2009, the State of Massachusetts terminated Medicaid funding for the project. However, two new funders have continued funding the project. Commonwealth Care Alliance continued the project for dually eligible seniors and soon will expand coverage to nearly all of Brightwood's dually eligible individuals under age 65. In 2011, Health New England restarted the model for Medicaid patients. Those populations represent 90 percent of all of Brightwood's patients. (Added November 2012)end fs

    Adoption Considerations

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    Getting Started with This Innovation

    • Negotiate access to capitated payment: This model works best when done in partnership with a capitated system with a large enrolled population.
    • Develop network of culturally competent providers: To be effective, all providers of medical, psychosocial, and support services must speak the language of the patients and know the environment in which they live. These providers should be willing to work with a population who have disabilities or chronic health problems.
    • Empower care coordinator: Personalized care coordination should be made available through a designated, empowered care manager. Coordinators must have the capacity and authority to intervene as early as possible when health care problems or addictions occur.
    • Provide high-risk enrollees with on-demand access: A separate call system for high-risk patients should be available around the clock.
    • Integrate services: If possible, medical, behavioral health, and long-term care services should be available within a single location.
    • Develop infrastructure-support system: This system should include comprehensive data management, strong contracting systems, and other types of support.

    Sustaining This Innovation

    • Involve nonprofessional peers: Support groups can provide tremendous benefits to those suffering from substance abuse or mental health problems.
    • Encourage teamwork: Although the primary care physician serves as the team's core member, nurses, clinicians, behavioral health specialists, and nonclinician team members must work together to review care plans and authorize care.

    Additional Considerations

    Brightwood worked with another nonprofit managed-care organization to obtain funding for a similar program for seniors enrolled in Medicare. This flexible financing allowed the center's providers to customize care to 500 seniors while reducing their per-member-per-month costs.

    More Information

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    Contact the Innovator

    Jeffrey Scavron, MD
    Medical Director
    Brightwood Health Center
    380 Plainfield Street
    Springfield, MA 01199
    Phone: (413) 794-4458
    Fax: (413) 794-5131

    Sara S. Bachman
    Associate Professor
    Boston University School of Social Work
    264 Bay State Road
    Boston, MA 02215
    Phone:(617) 353-1415

    Robert J. Master, MD
    President and CEO
    Commonwealth Care Alliance
    30 Winter Street, 11th Floor
    Boston, MA 02108
    Phone: (617) 426-0600, ext. 225
    Fax: (617) 426-3109

    Innovator Disclosures

    Dr. Bachman reported having no financial interests or business or professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

    Dr. Scavron and Dr. Master have not indicated whether they have financial interests or business or professional affiliations relevant to the work described in this profile.

    References/Related Articles

    Bachman S, Tobias C, Master R, et al. A managed care model for Latino adults with chronic illness and disability: results of the Brightwood Health Center intervention. Journal of Disability Policy Studies. 2008;18(4):197-204. Available at:


    1 Agency for Healthcare Research and Quality. National Healthcare Disparities Report, 2010. Rockville, MD: Agency for Healthcare Research and Quality, 2011. AHRQ Publication Number 11-0005. Available at:
    2 Bachman S, Tobias C, Master R, et al. A managed care model for Latino adults with chronic illness and disability: results of the Brightwood Health Center intervention. Journal of Disability Policy Studies. 2008;18(4):197-204. Available at:
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: October 10, 2008.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: December 18, 2013.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: November 18, 2013.
    Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.