Community-based care—or delivering health care and social services to the consumer wherever they are—comes in a wide range of program models, which vary in enrollment of consumers, the clinical professionals included on the care team, and the payer. But while different programs can vary significantly in their individual parts, most models involve to some degree wrapping serves around the consumer, coordinating their care, and building the skills to manage their own care.

Nancy Wexler

For more this month, we reached out to Nancy Wexler, Director of Innovation and Collaborative Care at Banner University Health Plan. Banner University Medical Group resides in the academic medical center at the University of Arizona. Banner University Health Plans (BUHP) began in 1985 as a Medicaid contractor and now has operations in Medicaid, Medicare Advantage (SNP), Long Term Care, and integrated behavioral health (BH). BUHP owns and operates: Banner University Family Care (BUFC) and Banner University Care Advantage (UCA). BUHP previously owned or managed University Heath Care Group, University Healthcare Marketplace, Maricopa Health Plan (MHO) and Maricopa Care Advantage (see Banner Health To Acquire Arizona’s Academic Health System).

Ms. Wexler specifically shared her work with The Healthy Together Care Partnership (HTCP)—a home-based collaborative care program started in 2014 and funded by Banner University Health Plans (see Innovative Community-Based Care Models For Consumers With Complex Conditions). The program’s features include co-management with primary care and home- and community-based services and seeks to align clinical care across disciplines while supporting the psychosocial aspects of care. Ms. Wexler explained:

We know that fragmentation in the health care system causes people to get lost and end up with problems managing their illness because of a lack of coordination of their care and because of poverty, lifestyle, social, and environmental factors. The most effective way to address these issues is to see someone in their home and work with their family members and all their health care providers.

The Healthy Together Care Partnership is an interdisciplinary care team at the Banner University Medical Group (BUMG) providing collaborative care management for complex adult patients insured through the Banner University Health Plans’ Medicaid and Special Needs Medicare Programs. We partner with BUMG primary care providers (PCPs) to help with transitions of care and to support the patient and family in their home to better manage their medical conditions and improve health care utilization.


HTCP is a clinical effort of BUHP and Banner University Medical Group Primary Care Providers serving Medicaid and Dual Eligible Medicare adults— 20% of HTCP population accounts for more than 85% of all program costs and HTCP aims to enroll 70% of the “top utilizers,” defined as having two or more chronic conditions, two or more hospitalizations, comorbid behavioral health. Ms. Wexler explained:

Our average population’s average age is around 56 years old, so it’s not all older adults. But it is complex adults. The population attributed to this program is 800 to 1000. Of those that are actively enrolled in the team services, those with actual home-based serviced is probably about 150 to 200 at any given time. All services are home based. Once in a while a consumer goes into a nursing facility and we would help with the transition, but services are mainly conducted in their home. Sometimes we will meet consumers at the actual clinic to collaborate with the physician, or that’s because that is where the consumer wants to meet.


Funding is fee-for-service (FFS) for clinical care rendered, and a per member per month (PMPM) care management fee for the total target population. In addition, there is a quality incentive bonus for achieving performance targets in several key areas: readmission rate; hypertension control; diabetes control; medication adherence; comprehensive health assessments; and annual wellness visits.


HTCP uses an interdisciplinary team consisting of a nurse practitioner, a clinical pharmacist, a behavioral health consultant, a registered nurse case manager, and a community health partner. Ms. Wexler explained:

A program manager directly supervises the team and they do have a comfortable office as a home base which is very important when they are out and about in a variety of environments all day. We have systems in place—cell phones and MiFi— that keep people connected in the field. There is a daily huddle and on Monday, staff and care planning meetings where the team members all attend in person. Staff performance is monitored in person and by discussing cases and reviewing chart documentation. A healthy team is our number one priority. You can’t support people in their home with challenging needs and dynamics if you can’t first support your team and be present and available to one another.


Ms. Wexler shared the latest performance numbers from the mid-year 2018 report, including performance on the 2018 Healthy Together Patient Experience/Satisfaction Survey, the 2018 PROMIS Survey Results, Emergency Department and Utilization Hospital Admissions, and the 2018 Diabetes Management Results.

The HTCP patient experience survey is a tool that HTCP uses to assess patient reported feedback regarding program satisfaction as well patient perception of their health status and ability to manage their health. This survey indicates that HTCP does particularly well in helping patients to gain an understanding of their medication and conditions so that they are better able to manage their health.

The Global PROMIS is a valid and reliable tool that HTCP uses to assess patients’ self-reported mental and physical health upon enrollment of the program. This assessment serves to determine need, level of intervention, and to set patients’ goals. The results are also used as a baseline in assessing the effectiveness of services. A follow up PROMIS is then administered upon dis-enrollment from the program or after a period of program participation to detect improvements over time. Our 2018 data show that those enrolled in HTCP scored significantly lower than the general population in their self-assessment upon enrollment. While the follow-ups have not all been conducted at this time, the early results based on the first few post-service respondents, point to improvements in both mental and physical perception of health.

In 2018, one of HTCP’s initiatives was to improve diabetes management in our patient cohort. The indicators that we used to measure the outcomes of this initiative were based on HbA1c testing frequency and values. From Mid cycle-July 2018, to the end of year, we measured the impact of those members with a diagnosis of diabetes and found improvements in both testing frequency and HbA1c values, including a 56% increase in the rate of testing for members whose HbA1c values had been at 9 or greater.

Using medical claims records from 2017 through October 2018, we evaluated the impact of the HTCP intervention on the utilization of health care services among participants. The analytic population is comprised of participants who were engaged in the program through July 2018 (to allow for claims run-out), with at least three months of claims history prior to and following HTCP assignment. These criteria resulted in a study population of approximately 200 participants, with an average age of 61 (at the time of HTCP assignment). Over 80% of this group (as well as the full 2018 HTCP population) was aged 50 or older.

We examined the emergency department visit and inpatient admission rates for this group prior to and following HTCP assignment (i.e. a pre-post comparison). While the analysis shows declines in both, the decrease in probability of an ED visits is statistically significant, pointing to a 30% decrease in ED use:

Pre-HTCP Post HTCP % Difference
ED Visit 12.8% 8.9% -30.8**
IP Admission 4.6% 3.7% -17.9




Ms. Wexler identified recruiting as a big challenge for this type of work—there is a need to find experienced staff in a limited recruiting pool, and then to provide that staff with all the support, structure, and communication tools necessary to do this unique job well. She explained some of the daily challenges, as well as the importance of technology in meeting the requirements of the job:

It’s hard when people no show if you’ve driven to their home. Driving long distances is challenging and reduces efficiencies. Meeting people where they are is hard if the home environment isn’t conducive to an exam or conversation -some people have animals, leave their TV at high volume, or have smoke in the air. Often homes in Arizona are not cooled in the summer so it can be “suffocatingly” hot. People often ask us about personal safety. This has not been a major concern for our team in the six years we’ve run this program. The benefits of this work and of being ion the home environment to better connect with people’s social situations far outweigh the sacrifice.

We can’t function without our iPhones! We also use laptop computers and MiFi devices to log into the electronic health record (EHR) and obtain educational information. We have personal printers as well. Finally, we just added a great new technology called Pyx. It’s a smart phone app and it uses a carebot (chatbot technology) to interact with our participants and assess their mood. It reminds them to engage in their chosen health-promoting behaviors. What’s really special about it is that it also engages their identified care loop—people who they deem to be their “natural supports” and who can have access to their mood scales and other important info. It’s been a great addition.

Banner University Health Plans (BUHP) is the only locally owned plan focused exclusively on Arizona and is a recognized Medicaid managed care leader. It has pursued transformation through innovation, reinvention and continuous learning. In 1985, it began as a Medicaid contractor and now  has a history of successful operation in Medicaid, Medicare and integrated behavioral health (BH). BUHP owns and operates: University Family Care (UFC), Banner-University Family Care (BUFC), and University Care Advantage (UCA).

Year Founded: In February 2015, the Health Plans merged with Banner Health. As such, UAHP operates as one component of an integrated health care system that includes Banner ‒ University Medical Center Tucson Campus and South Campus as well as a comprehensive network of Banner Health primary care and specialty care providers.

Contact Info

2701 E. Elvira Road
Tucson, AZ 85756
(877) 874-3930