Dually eligible individuals with serious mental illness (SMI) — who represent one third of all dual eligibles under age 65 — have complex needs that are challenging to address in a coordinated manner due to siloes between medical, behavioral health, and social care systems. Commonwealth Care Alliance (CCA), a health care organization that serves dually eligible individuals within two integrated products and receives fully capitated blended payments, developed a unique approach to address the needs of the growing member population with SMI. This case study illustrates CCA’s promising practices to meet the needs of dually eligible individuals with SMI, and emphasizes opportunities to innovate with flexible spending within a capitated payment model.
CCA created enhanced crisis stabilization units and an integrated mobile health program to reduce acute care utilization for mental health issues, such as inpatient psychiatric hospitalizations and unnecessary emergency department visits. Based on the level of complexity, CCA adjusted care team structures with the goal of optimizing the balance of behavioral, medical, and social care based on members’ existing relationships with providers. Levels of care designated based on this stratification include behavioral intensive, medical and behavioral intensive, in-home care coordination, phone care coordination, and care coordination outsourced. As trusted, long-term relationships are critically important for people with SMI, CCA also established partnerships with behavioral health community providers for members. Other entities leading integrated models of care can apply these lessons to more effectively support their members with serious behavioral health needs.