Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs

Clair, Catherine A.; Sandberg, Shana F.; Scholle, Sarah H.; Willits, Jacqueline; Jennings, Lee A.; Giovannetti, Erin R.

doi:10.1186/s41687-022-00445-y

Journal of Patient-Reported Outcomes

Table 1 Participating sites

From: Patient and provider perspectives on using goal attainment scaling in care planning for older adults with complex needs

Location	Type of organization	Settings of care	Patient population served	Integration of care with primary care	Clinicians interviewed	Patients interviewed
Ohio	Case management for Medicare-Medicaid Managed Care Plan¹	Telephone Home	Low-income older adults with long-term care needs	Case managers work with networked providers but are not integrated into primary care practice	4	1
Wisconsin	Case management program in Medicare-Medicaid Dual Eligible Special Needs Plan²	Home	Low-income older adults with long-term care needs	Case management team works with networked providers but are not integrated into primary care practice	2	7
Michigan	Transitional-care case management program in Medicare Advantage Plan³	Skilled Nursing Facility (SNF) Telephone	Older adults with complex medical conditions	RN case managers work on site at SNF to facilitate transition to community	5	7
California	Accountable care organization (ACO)⁴ case management program	Clinic Telephone	Older adults with complex medical conditions	Case managers work with primary care practice and ACO-affiliated specialists to coordinate care	4	5
Oregon	Medical home case-management program in integrated provider-health plan network⁵	Clinic Home Telephone	Home-bound older adults	Case management team is part of medical home and integrated into primary care practice	4	2
California	Geriatric home-based primary care	Home	Home-bound older adults	Physician and nurse practitioner provide primary care in the home	1	2
Texas/Michigan	Geriatric home-based primary care	Home	Home-bound older adults	Physician and registered nurse provide primary care in the home. Home care and hospice provider offices are co-located	3	4

¹Private health insurer funded by the U.S. federal government and enrolls both Medicare and Medicaid beneficiaries. Medicaid payments are realized through contracted arrangements between state agencies and managed care organizations that accept a set per member per month payment for services
²Private health insurer funded by the U.S. federal government that enrolls individuals entitled to both Medicare and medical assistance from a state plan under Medicaid
³Medicare-approved private health insurance company that provides bundled services (Parts A, B, and D) of Medicare
⁴Group of doctors, hospitals, and other health care providers that provides coordinated care to Medicare patients. Accountable care organizations tie provider reimbursements to quality metrics and reductions in the cost of care
⁵A private (non-government) health system with integration of the delivery of health care, including integration of the electronic health record. Serves patients with private and public insurance

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