“Caring for the complex chronically ill accounts for a high proportion of national spending and spans the healthcare system” according to Cathy Schoen, Senior Vice President for the Commonwealth Fund. She was speaking at the Alliance for Health Reform briefing “Improving Care and Managing Costs: Team-based Care of the Chronically Ill” held on Capitol Hill August 11th.
Schoen reports, “Twenty one percent of spending is for the five percent of the population that has five or more chronic conditions. Payment changes, team-based care, and system innovations including the use of registries and EHRs are key to achieving better outcomes and lowering costs.”
How to provide team-based care for dual eligible seniors with complex chronic conditions was described by Lois Simon, M.P.H., Co-Founder and Chief Operating Officer for the Commonwealth Care Alliance (CCA). CCA is a Massachusetts state-wide not-for-profit consumer governed prepaid care delivery system taking care of Medicaid and/or dual eligible seniors with the most complex and expensive chronic conditions.
CCA put in place a primary care and care coordination model by deploying multidisciplinary primary care teams. To further explain, Simon presented a case which needed a fundamental primary care redesign.
Anna C. a 55 year old woman SSI eligible Medicaid beneficiary, was ill with long standing Multiple Sclerosis resulting in completer paralysis in both legs, partial paralysis in both arms, and impaired bladder function. This has resulted in a long standing history of depression, a prior major suicide attempt, and a history of severe asthma exacerbated by heavy smoking.
For many years, Anna was able to use a manual wheelchair and perform self catheterizations but with slowly progressive upper extremity weakness this became impossible for Anna. To help her, Anna received two hours of care from a Personal Care Assistant each morning and each evening for the past five years without any adjustment despite her functional decline.
During the past two years, there have been multiple hospitalizations for urinary tract infections, asthma exacerbations, and two long sub-acute hospital stays for pressure sore management caused by extended hours in bed and from a poorly fitted manual wheelchair.
Anna was found to have no consistent primary care or behavioral health relationship and as a result, she was severely depressed, emotionally withdrawn, functionally bedbound, incontinent, and experiencing rapidly worsening ulcers.
Obviously, continuity clinical management in Anna’s care was non-existent and not only reflected in her lack of care, but also influenced the cost factor. Costs and service use patterns with individuals such as Anna’s represent 12 percent of Medicaid beneficiaries, and represent 30 percent of Medicare expenditures. Anna’s predicted monthly total medical expenditures are about $3800 per month with nearly 50 percent going to recurrent hospital care for predictable complications from her chronic illnesses.
At this point, a primary care redesign was implemented for Anna. A team was put in place to include an in-home nurse practitioner, a behavioral health clinician, plus physical therapy is provided, along with durable medical equipment to enable the following individualized care plan:
• 72 hours of personal care assistant support per week was instituted to help with daily living activities but was later reduced to 40 hours a week over time
• A consultation with an in-home wound care nurse specialist provided a clinical management plan
• A specialized air mattress was delivered within 24 hours along with a motorized wheelchair with needed seating adaptations
• An in-home behavioral health assessment was made along with an individualized care plan that includes medications and counseling
• Transportation was arranged for specialty appointments, dental care, and other activities
• Smoking cessation strategies were instituted
• A primary care physician with support by a nurse practitioner responds first to new problems via home visits.
One year later, Anna was engaged with life, family, community and was able to self manage her care which greatly improved. Also, ulcers were healed, behavior health, psychopharmacology. and in-home counseling was established, smoking cessation efforts were partially effective, asthma exacerbations were greatly diminished, and a continuous relationship with the primary care physician was established although more primary care occurs via a nurse practitioner in the home.
Most importantly, there were only two emergency department visits for asthma exacerbation management and one three day hospitalization for urinary tract infection management, and as a result, hospital utilization was markedly lower than before.
The CCA team-based approach works well with Medicare and Medicaid patients with five or more chronic conditions. According to an AHRQ report “The roles of “Patient-Centered Medical Homes and Accountable Care Organization in Coordinating Patient Care” published December 2010 discusses in detail what has not worked in providing coordinated care.
The report finds that targeted care coordination services provided to low-risk Medicare patients have not been shown to improve the quality or utilization of care and at times have increased overall costs. However, well-designed, targeted care coordination interventions delivered to the right people with multiple chronic conditions can improve patient, provider, and payer outcomes.
Several successful coordinated care models in the U.S show major reductions in emergency room visits, reductions in all-cause hospital admissions, readmissions, nursing home days, and indicate that these care models have achieved net savings and improved quality outcomes especially for high risk patients.
