Improving Care Coordination for Dual-Eligible Individuals: Strategies for Better Health Outcomes

For individuals who qualify for both Medicare and Medicaid—commonly known as dual-eligibles—navigating the healthcare system can be daunting. These individuals often have multiple chronic conditions, require long-term care, and experience socioeconomic barriers that complicate their ability to access necessary services. Because they must interact with two distinct healthcare programs with different rules, providers, and benefits, care fragmentation is a frequent issue, leading to gaps in care, medication mismanagement, and preventable hospitalizations.

Care coordination becomes a critical factor for addressing these challenges. By integrating medical, behavioral, and social services, healthcare providers can ensure dual-eligibles receive comprehensive, high-quality care tailored to their unique needs. One of the most promising models for achieving this is through Dual Eligible Special Needs Plans (D-SNPs), which help streamline the administration of benefits and improve health outcomes. 

Understanding the Unique Needs of Dual-Eligibles

Dual-eligible individuals represent one of the most medically and socially vulnerable populations in the healthcare system. Many suffer from multiple chronic illnesses such as diabetes, heart disease, and mental health disorders, requiring ongoing medical attention, prescription medications, and specialized treatments. Additionally, this population has a high prevalence of disabilities, cognitive impairments, and functional limitations, often necessitating long-term services such as home health care, nursing home care, or personal assistance for daily activities.

Beyond medical needs, social determinants of health play a significant role in the well-being of dual-eligibles. Many individuals face economic instability, inadequate housing, food insecurity, and lack of transportation, which can create additional barriers to accessing healthcare. Without proper support, these non-medical factors can lead to worsening health conditions, increased hospitalizations, and reduced quality of life.

Given the complexity of their needs, dual-eligibles require a coordinated, patient-centered approach that not only manages their medical conditions but also provides social support and addresses systemic barriers to care.

The Role of Dual Eligible Special Needs Plans (D-SNPs)

One of the most effective mechanisms for improving care coordination among dual-eligibles is through Dual Eligible Special Needs Plans (D-SNPs), a type of Medicare Advantage plan specifically designed to integrate Medicare and Medicaid benefits. Unlike traditional fee-for-service models, where patients and providers must navigate two separate systems, D-SNPs offer a more unified approach to healthcare delivery, helping streamline access to services and reduce inefficiencies.

D-SNPs vary in their level of integration:

• Coordination-Only D-SNPs: These plans provide some level of care coordination but do not fully integrate Medicare and Medicaid benefits.
• Highly Integrated Dual Eligible Special Needs Plans (HIDE SNPs): These plans integrate medical and long-term care services but may not fully align Medicaid and Medicare benefits under a single entity.
• Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs): These plans offer the highest level of integration, managing both Medicare and Medicaid benefits within one organization, ensuring seamless service delivery and reduced administrative burdens for patients.

By enrolling in a D-SNP, dual-eligibles can receive better-coordinated care, enhanced provider communication, and improved access to additional benefits, such as transportation, meal assistance, and case management services.

How to Enroll in a D-SNP

To enroll in a D-SNP, confirm you’re eligible, decide how you’d like to enroll, and complete the enrollment process.

1. Confirm Eligibility:
   • Must be eligible for both Medicare and Medicaid
   • Must live in a state/county where D-SNPs are offered (availability varies by location)
2. Choose an Enrollment Method:
   • Online: Complete and submit an online enrollment application
   • Phone: Call the insurance provider directly
   • In-person: Meet with a licensed insurance agent
3. Complete the Enrollment Process:
   • You will need to answer a series of questions about your eligibility
   • Provide documentation for both Medicare and Medicaid coverage
   • Select your preferred plan from the available options in your area

Before beginning the enrollment process, it’s helpful to research available D-SNP plans in your area, compare benefits and coverage options, and contact the insurance provider to answer specific questions about plan options. You may also choose to work with a licensed agent to navigate the process.

1. Check Your Eligibility – You must be eligible for both Medicare and Medicaid in your state.
2. Find a D-SNP in Your Area – Use the Medicare Plan Finder or check with private insurance companies that offer D-SNPs in your state.
3. Gather Required Information – You may need:

• Your Medicare Number (found on your Medicare card)
• Proof of Medicaid eligibility (from your state Medicaid office)

4. Enroll During an Eligible Enrollment Period – You can enroll:

• When you first become eligible for Medicare and Medicaid
• During the Medicare Advantage Open Enrollment Period (January 1 – March 31)
• During the Annual Enrollment Period (October 15 – December 7)
• If you qualify for a Special Enrollment Period (SEP) (e.g., changes in Medicaid status)

5. Submit Your Application – You can enroll by:

• Contacting the insurance company directly
• Applying online through Medicare’s website
• Calling 1-800-MEDICARE (1-800-633-4227) for assistance

Key Strategies for Effective Care Coordination

To improve health outcomes for dual-eligibles, care coordination efforts must be structured, proactive, and patient-focused. Below are the most essential strategies for effective coordination:

1. Conducting Comprehensive Needs Assessments

Effective care coordination begins with a comprehensive needs assessment that evaluates an individual’s medical, behavioral, and social needs. These assessments help care teams identify chronic conditions, disabilities, and mental health concerns, ensuring that appropriate treatments and support systems are in place. Additionally, they allow providers to evaluate medication regimens to prevent adverse drug interactions, assess functional limitations that may require long-term services, and address social determinants of health—such as housing instability or transportation barriers—that can impact access to care. By conducting thorough evaluations, care coordinators can develop a holistic, customized care plan that aligns with the individual’s specific needs and enhances their overall well-being.

2. Developing Person-Centered Care Plans

Developing a person-centered care plan is crucial to aligning treatment decisions with the patient’s goals, preferences, and overall quality of life. These plans outline treatment priorities and establish long-term care goals while incorporating input from primary care physicians, specialists, and social workers to ensure a comprehensive approach. By integrating essential services like home health care, rehabilitation, and behavioral health support, person-centered care plans provide a cohesive framework that adapts over time to meet the patient’s evolving health status. This dynamic, individualized approach fosters better patient engagement and improves adherence to treatment regimens, ultimately improving health outcomes.

3. Managing Care Transitions Effectively

Dual-eligible individuals often move between various care settings, such as hospitals, skilled nursing facilities, and home care, making care transitions management a critical component of effective care coordination. Poorly managed transitions can result in medication errors, delayed follow-ups, and preventable hospital readmissions. To mitigate these risks, assigning a transition care manager to oversee the discharge process ensures continuity of care. Additionally, providing thorough medication reconciliation helps prevent errors, while scheduling timely follow-up appointments with primary care providers reduces gaps in treatment. Connecting patients with home-based or community-based support services further enhances their recovery and stability. When transitions are well-coordinated, patients experience fewer complications, better adherence to care plans, and a significantly lower risk of hospital readmission.

4. Improving Provider Communication and Data Sharing

Poor data sharing can lead to incomplete medical histories, duplicated services, and unnecessary delays in care. To mitigate these challenges, healthcare organizations should implement interoperable health information systems that enable providers across different networks to seamlessly access patient records. The use of electronic health records (EHRs) plays a crucial role in reducing gaps in medical history documentation, ensuring that all care team members have access to up-to-date information. Additionally, establishing care coordination teams that include representatives from both Medicare and Medicaid sectors fosters better collaboration and alignment of services. By improving provider communication and data-sharing capabilities, healthcare teams can deliver more cohesive, efficient, and patient-centered care, reducing confusion for both patients and providers while enhancing health outcomes.

5. Addressing Social Determinants of Health

Addressing social determinants of health (SDOH) is essential in improving outcomes for dual-eligible individuals, as medical care alone is not sufficient to support overall well-being. Many factors, such as transportation, nutrition, housing, and mental health, directly impact a patient’s ability to access and adhere to treatment plans. Care coordination teams should collaborate with community-based organizations to provide essential services, including transportation for medical appointments, nutritional support through home-delivered meals and food assistance programs, and housing resources to ensure stable living arrangements. Also, integrating behavioral health services helps address mental health conditions and substance use disorders, which are often prevalent in this population. By embedding social support into healthcare planning, providers can reduce barriers to care, enhance patient engagement, and promote better long-term health outcomes for dual-eligibles.

Overcoming Challenges in Care Coordination for Dual-Eligibles

Despite significant progress in improving care coordination for dual-eligible individuals, there are still many challenges. Navigating the complex healthcare systems of Medicare and Medicaid, each with its own set of rules and regulations, can create confusion for both patients and providers. Additionally, limited data integration between state and federal programs makes it difficult to share medical histories and coordinate care effectively. Workforce shortages in case management and care coordination roles further strain the system, reducing the capacity to provide personalized support. Financial constraints also pose a barrier, limiting access to enhanced services that could improve health outcomes. Overcoming these challenges requires policy changes, investment in technology, and continued innovation in care coordination models to ensure that dual-eligible individuals receive seamless, high-quality care.

Conclusion: Moving Toward a More Integrated Future

For dual-eligible individuals, care coordination functions as a lifeline that ensures members  receive the right care at the right time. By leveraging D-SNPs, personalized care planning, improved data sharing, and social service integration, healthcare organizations can bridge critical gaps in care and enhance the health outcomes of this vulnerable population. As healthcare evolves, continued efforts to streamline processes, enhance provider collaboration, and address social determinants of health will be essential in creating a more efficient and equitable system for dual-eligibles.