By Ira Green
Frail elderly patients who cannot care for themselves make up only about 1 percent of medical cases. However, this group is also the most expensive to care for.
When frail elderly people have access to care, either through Medicare, Medicaid, private insurance, or family assistance, their experiences in navigating the healthcare system can be frustrating, at best. With such a fragmented system, it can be nearly impossible to ensure that these patients access the tests and treatments they need in a way that ensures no duplications or adverse reactions.
Not surprisingly, a large percentage of the frail elderly currently end up in costly nursing homes and other long-term care facilities. Although that may be the best option for some, others would be able to stay in their homes if they had the right types of assistance.
CenterLight Health System is making this possible in New York City. A provider of a broad spectrum of long-term care services to more than 12,000 patients a day, CenterLight created a model that helps senior patients receive coordinated care in their homes at a cost to the state that is tens of thousands of dollars a year less per patient than residence in a nursing home.
CenterLight's model could not be more timely. This year, Medicaid in New York State is about to undergo significant reform that requires all long-term care patients to be in managed care plans in the near future. By January 2013, the managed care phase will have started in all five boroughs of New York, plus nearby Nassau, Suffolk, and Westchester counties.
The key, according to CenterLight, is making the patient the top priority. "Sure, it sounds cliché," says Joseph Healy, COO, of CenterLight Healthcare's managed care unit. "But it's absolutely the foundation of our efforts from direct care to administration. We want every patient to have a better quality of life. That's what matters most to them, so that's what matters most to us. Every aspect of their care points to this goal."
That philosophy plays out in a number of practical ways that help the health system better care for patients and save state Medicaid dollars. The CenterLight program uses managed care, a team approach to clinical decisions, and physician waivers to improve quality of life for patients while using available Medicaid and Medicare funds wisely.
PACE managed care program. CenterLight runs one of the nation's largest and oldest PACE programs, with PACE standing for The Program for the All-Inclusive Care for the Elderly. PACE is funded through a capitated model. CenterLight receives a certain amount of money per patient per month?in a combined payment from Medicare and Medicaid?to coordinate care for frail, dual-eligible elderly patients. Offered today in 29 states, PACE is expanding throughout the United States as a model of care that can better meet the needs of long-term care patients.
"Our growth reflects the increased emphasis on coordinated care that is occurring throughout health care," said Shawn Bloom, president and CEO of the National PACE Association. "PACE demonstrates that coordinated care can improve the well-being of patients and bolster financial predictability."
The focus of PACE is to keep the patient at home, living independently with a community social network, as long as possible. CenterLight makes this possible through adult day-care centers that offer recreational therapy and primary care in the patient's neighborhood. Home care nurses also visit with patients to administer medical care.
"We have one patient who was alone, living in half a bedroom with a family member who had to work," says Healy. "Without PACE, this patient would be isolated and not receiving the medical care she needs. Instead, she has companionship and medical care that are enhancing her quality of life despite her challenging living circumstances."
In some cases, to create better efficiency as well as constant access to care, CenterLight patients benefit from a cluster-care program that brings nurse aides to an apartment or floor where three or four patients live. That arrangement allows nurses to focus their efforts on delivering care rather than travelling between patient homes.
The team approach. CenterLight's managed care programs operate in a hub-and-spoke model. At the center is the patient who works initially with a nurse to develop an appropriate care plan. The nurse focuses on understanding the patient's needs and determining from the assessment the next steps for care.
"Understanding everything about patients' needs goes far beyond their medical care," says Mary Wehrberger, vice president of clinical operations. "We look at social, emotional, mental, spiritual, and cultural norms for each patient so that the care we provide meets those needs."
Next, the nurse works with an interdisciplinary team of physicians, social workers, therapists, and other medical professionals who are chosen based on the patient's needs. The team's task is to ensure the right tests are administered, the results are known to everyone, and the care plan is created without any possibility of duplication or adverse reactions. As the primary point of contact, the nurse then walks the patient through the entire care process, maneuvering and coordinating the patient's changing needs.
Healy adds, "When you talk and coordinate, you eliminate duplication, make sure medications are not interacting adversely, and discover out-of-the-box ways to treat patients. In one case, our care team noticed that an elderly couple was going to the emergency department for heat exhaustion. When we visited the couple's apartment, we noticed it had no air conditioner. So, we purchased one, and the couple stopped going to the emergency department for that same issue. The cost of the air conditioner paled in comparison to their emergency department visits."
Because CenterLight is located in the diverse urban setting of New York City, it pays special attention to diversity. Patients' cultural backgrounds make a difference in how they want to be cared for. For example, they may be attached to a non-Western medical treatment, which guides the care team to integrate that preference into an effective medical care plan.
Physician waiver. As a new benefit of PACE, CenterLight is one of the few organizations in the nation that has received a waiver from the Centers for Medicare & Medicaid Services that allows some patients to see any physician they choose-not just a PACE physician who is employed by CenterLight.
The key is relationship building with a physician who knows the patient's needs already. Starting fresh with a new caregiver requires repeating tests, exams, and conversations that have already occurred with a prior physician. That involves wasted time and dollars that could be spent on patient care.
"That relationship with the doctor and patient is so important," says Stephan Deutsch, MD, chief medical officer, CenterLight Healthcare. "This waiver is a good step in the direction of keeping that bond, and also allows doctors to focus on care for the patient, leaving the rest of the patient's team to coordinate other needs. We anticipate cost savings to rise as we further implement this plan."
This community physician program is in its beginning stages, but CenterLight hopes it will be a model for the nation in the near future.
CenterLight's three-fold approach helps senior patients maintain dignity and independence, while limiting costs. The following statistics offer tangible results from CenterLight's program:
Better outcomes. Only 6 percent of CenterLight PACE members permanently reside in nursing homes. Similar statistics for the nursing home certifiable population of New York State Medicaid fee-for-service patients hover at 50 percent, according to a report released by the New York State Department of Health. That means the program is working by keeping patients in their homes when it's possible to do so. With more care delivered in the home, the costs for housing patients in nursing homes decreases.
Reduced hospital stays. Furthermore, hospital days for CenterLight PACE members are 26 percent lower than a similar population of Medicaid recipients living in nursing homes across the nation in recent years, as reported by the National PACE Association.
Significant reduction in annual costs of nursing home stays. The combined annual cost to New York State's Medicaid program and Medicare for a single patient in CenterLight's PACE program is about $80,400. That compares with approximately $105,060 in costs to Medicaid only for residence in a nursing home. That figure does not include the costs to Medicare associated with the resident's medical care. So for 75 percent of the cost of nursing home residency, CenterLight PACE provides substantially more services while keeping individuals safe at home in the community.
CenterLight's PACE program is successful in reducing costs and raising the quality of care for critical-care elderly patients. Although those accomplishments are admirable on their own, CenterLight takes healthcare delivery a step further and addresses the personal needs and diversity of its patient population.
Ira Green is senior vice president/CFO of CenterLight Health System, New York City, and is a member of HFMA's Metropolitan New New York Chapter (email@example.com).
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