• Coordinating the Doctor's Orders

    Apr 21, 2010

    As payers slowly begin to reward providers for keeping patients healthy-and out of the hospital- forward-thinking healthcare leaders are wisely investing in care coordination strategies.

    This is Section 4 of Leadership's Collaborating for Results report.

    Return to the full report.

    A physician writes a prescription. But what guarantees that the patient will actually get the recommended test or treatment? As detailed in these case studies, providers are finding the greatest success with a low-tech, high-touch approach: connecting patients with dedicated, caring staff members.

    Case Study: Navigating Toward Health

    When Virtua health system interviewed patients to get a picture of healthcare delivery through the user's eyes, the feedback was not encouraging.

    "Patients told us we have a bunch of disparate processes, and they are not really sure what is sequential and what is connected," says Ninfa Saunders, PhD, RN, MSN, Virtua's executive vice president and COO for health services. "They talked about the difficulty of navigating a large system with multiple services, multiple nomenclatures, and brand names-not to mention all the acronyms we use for the various programs we have."

    The largest provider system in southern New Jersey, Virtua comprises four hospitals and a wide range of healthcare facilities and services. Recognizing how bewildering a large healthcare system can be, Virtua decided to collaborate with patients to help them identify and use health services more proactively and appropriately.

    Managing health.
    The goal is to reposition Virtua as patients' "go-to source" for getting and staying healthy. Saunders wants patients to see Virtua not as a group of hospitals and outpatient services, but rather as a resource for good health.

    "We want to expand our focus to include wellness," says Saunders. "If we really are going to be a responsible and accountable healthcare organization, we have to look at all facets of health. Our focus is not limited to 'providing healthcare services' but must include helping patients manage health."

    To move in that direction, Virtua is developing one of the most comprehensive patient navigation programs in the country (see the sidebar). As the term suggests, navigation programs help patients circumvent the many barriers-financial, logistic, social, and others-that make it difficult to use the healthcare system effectively and efficiently.

    Providing one-on-one contact. People helping people is at the core of patient navigation, and 16 navigators are currently on the job. Every patient or community member who uses one of Virtua's navigation programs has one-on-one contact with one of those specially trained Virtua staff members.

    Nurse navigators help patients manage their disease, coordinate care, and review treatment options. Nonclinician navigators help patients and community members identify appropriate providers and schedule appointments. There will even be health coaches available to help community members lose weight and make other healthy lifestyle changes.

    "We will have navigators available to help patients at every point of the healthcare continuum-from wellness all the way to long-term care," says Saunders.

    Building on success. Virtua's first foray into navigation came three years ago, when the system started a breast care navigation program. Nurse navigators were assigned to patients with suspicious mammograms. During the pilot program, the lag time from initial mammogram to appointment with a breast cancer surgeon dropped from 30 days to 12 days, providing women with the focused attention they want during a health crisis.

    A positive business side effect: More than 99 percent of patients who needed breast cancer surgery chose to stay with Virtua for their surgery and/or treatment, up from 50 percent before navigation services were offered.

    Recognizing the opportunity to transform care delivery, Virtua moved quickly to build a comprehensive navigation program in 2009. While still young, the program is helping the system prepare for the future. Virtua leaders are not too worried about how much the fast-growing corps of navigators will cost because of how much the health system can save when patients use healthcare services more appropriately.

    Preparing for future changes. Robert Segin, Virtua's vice president and CFO, says providing patient navigation will help Virtua thrive when the accountable care organization (ACO) model takes hold. Under an ACO model, healthcare organizations will be paid to care for the health of a population of patients. So taking steps to keep people healthy and helping them quickly access the right type of healthcare services should translate into reduced use of costly inpatient services.

    "Our book of business has been so focused on acute care and interventional care when we want to also focus on wellness," says Saunders. "That's where the challenge is."

    Case Study: Cooperating with Payers

    Patients visiting Swedish Community Health, a medical home clinic started by Swedish Medical Center in Seattle early last year, are not shuffled through the exam room in 15-minute increments.

    Primary care appointments are typically scheduled for 30 minutes or 60 minutes. Insured patients have no copayments or deductibles so they seek care when they need it, not when they can afford it. Self-pay patients, including those with high-deductible health plans, pay a flat rate of $45 a month. Low-income uninsured patients are treated for free. All recommended preventive care is provided to all patients.

    "We are completely throwing the old rules out the window," says Jay Fathi, MD, Swedish's medical director of primary care and community health.

    The clinic is designed as a pilot with the goal of creating a sustainable, replicable model that delivers preventive and primary care efficiently, helping to solve America's healthcare cost crisis. At full capacity, the clinic will accommodate 2,000 patients. Currently, more than 900 patients are enrolled.

    "We have very significant, practically daily demand, from more self-pay patients who wish to enroll," says Fathi, explaining that "self-pay" includes both patients who can afford to pay for their care and those who cannot.

    Partnering with payers. In establishing the clinic, Swedish executives worked with two major payers to set up a new type of relationship: Molina Healthcare, a Medicaid managed care plan, and Premera Blue Cross, the largest private insurer in the market.

    "We meet in a very collaborative spirit because we have aligned goals to improve the health outcomes of the population and to save costs," says Fathi. "When you sit down with a payer with these shared goals, it's not that difficult to come up with the metrics. We don't want to get paid on volume. We want them to pay us to do the right thing."

    The challenge of starting from scratch is that no one knows what will work. Commercial payers in the Seattle area spend roughly $250 to $280 per member per month, of which $18 to $25 goes to primary care providers.

    "Our proposal to the commercial payers is, 'You pay more on the front end, and we'll change the system so you'll save more overall,'" says Fathi. "But this is pioneering thinking, and no one really knows what the market for this is."

    For example, Premera is paying a fixed fee per member per month-with bonuses for good performance on quality and process measures-to Swedish for primary care, but whether the total amount paid is sufficient will take time to tell. Dr. Fathi thinks the clinic's services will prove to be worth more than the insurer's original contract stipulates, but that will have to be proven over time.

    Saving over time. Another challenge: Getting people to see the value in spending money upfront on preventive and primary care-to save greater expenditures down the road.

    "When an uninsured, low-income patient comes into the clinic, we should not view that patient as a financial loss for the medical practice," says Fathi. "We need to look at this systemwide, and remember that we can save $650 if we keep this patient from going to the emergency department (ED)."

    Learning as they go. The practice is staffed with medical teams that include family-medicine physicians and residents, nurse practitioners, physician assistants, and nurse care managers. Nurses help coordinate patient care, teach patients to access their medical records online, and facilitate communication between members of the medical team and specialists.

    Patients are encouraged to contact their medical team by email or telephone, if needed, and to think about their health issues broadly when they schedule an appointment. Instead of the normal 15-minutes- per-patient pace, a physician can spend an hour with a patient-and his or her next appointment may not be needed for several months.

    Since opening in March 2009, the medical home practice has been viewed as a pilot in which everything-staffing mix, length of appointments, quality metrics, and per member per month charges-is being evaluated.

    In its first year, Swedish leaders have also learned some good lessons about the medical home model. For starters, do not underestimate the importance of the nurse care manager role. "We are just now learning about the optimal ways to train and use this key position," says Fathi.

    Working out the business model. "This is one of our answers to healthcare reform," says Jeffrey D. Veilleux, Swedish' executive vice president and CFO. "When we're being asked to provide more access to care and to deal with decreasing reimbursement throughout the system, it makes sense to find creative solutions to providing care in the most efficient way."

    The most efficient formula, of course, will take a while to reveal itself. For example, redirecting low-income uninsured patients from Swedish's hospital ED for primary care saves money. However, within months of opening, the medical home clinic was seeing its no-pay patient volume rise too quickly.

    "Our plan was, in addition to an innovative financing structure for primary care, to also help relieve the pressure for caring for the long-term uninsured," says Fathi. "Obviously, we'll have to cap the number of no-pay patients at the clinic."

    The goal is to limit the no-pay uninsured patients to 10 percent of the total patient population served by the clinic.

    In its initial phases, the medical home pilot is receiving financial support from Swedish Medical Center Foundation. Veilleux is optimistic that, in the long run, the model will prove itself financially and justify replication in other Swedish primary care practices-and in other health systems around the country.

    "We expect that we can run the clinic at break even, and hopefully, we can do better than that with good management," he says.

    Case Study: Quarterbacking the Patient Care Team

    At Gundersen Lutheran Health System, a chronically ill patient with complex medical issues, inadequate or overwhelmed social support, and a history of heavy health services utilization is seen as an opportunity to save money.

    That's because Gundersen Lutheran's care coordination program, which targets the sickest 1 percent to 2 percent of patients, has proven that it can reduce healthcare costs by more than $15,000 per patient over two years.

    "Our primary focus is getting the right care for the patients," says Diane Larson, RN, administrator director at Gundersen Lutheran Heart Institute, who oversees the care coordination program. "But this program also supports our business objective of saving the system money."

    Helping with transitions. The program began in 2003, and more than 1,400 patients are currently receiving care coordination. A registered nurse (RN) and social worker collaborate with a patient's healthcare team to develop a care plan, help with transitions between inpatient units, arrange for needed social services, and schedule and attend outpatient appointments. They also arrange care conferences- by phone or in person-to help members of the care team share information, particularly during transitions between care settings.

    The coordination is possible in large part because Gundersen Lutheran is an integrated system with an EHR that spans inpatient and outpatient care.

    "We can be that one constant contact person for the patients and the providers and the family," says Lois Tucker, RN, one of the care coordinators.

    Reaching out to patients in need. Gundersen Lutheran's service is available to patients of all ages and any diagnoses. Patients are assigned to coordination if they have:

    • Frequent hospitalizations or ED use
    • Frequent falls
    • Multiple medications
    • Multiple healthcare providers or chronic conditions
    • An inadequate home support system
    • Difficulty coping with their healthcare needs
    • An inpatient stay of more than 14 days
    • An inpatient bill of $100,000 or more

    "A lot of care coordination patients have diabetes, chronic renal failure, heart failure, and multiple diseases, of course," says Tucker. "But one of the common threads is that the patients may have underlying depression or anxiety, which affects their ability to cope and manage their health care. So we have coordinators who are experts in behavioral health."

    The challenges of helping this population of patients requires highly experienced nurses and social workers. In fact, the care coordinators have, on average, more than 20 years experience. They need extensive experience to know how to assess the patients' functional, psychological, and medical status; where to find resources; and how to work with social workers (who can provide resources, such as transportation to appointments and money for medications) and the entire healthcare team.

    "We call ourselves detectives because we have to uncover what the real problems are, and we assist the patients and their families in navigating the healthcare system," says Tucker.

    Balancing costs and charges. A 2005 evaluation of 222 patients found that it costs Gundersen Lutheran an average of $2,200 a year to coordinate the care of a typical patient. In contrast, the average charges for a patient enrolled in care coordination decrease by $7,300 in the first year services are delivered.

    Shifting from high-cost inpatient and ED care to outpatient clinics cut total charges from $7.1 million to $3.7 million. And for every $1 Gundersen Lutheran invests in care coordination, healthcare charges for those patients fall by about $3.

    That is a mixed blessing for health system. Because some of the patients in the care coordination program are enrolled in the system's own health plan, some of the savings accrue to the health system. As of January, 381 patients-or 27 percent of the care coordination caseload-were covered by Gundersen Lutheran Health Plan.

    However, reduced revenues from patients covered by other health plans does impact Gundersen Lutheran's bottom line.

    "What we like to focus on is that this is part of our mission-to improve the health of the communities we serve-and this program does that," says Tucker.

    Currently staffed by 22 RNs and four social workers, Larson and her team are assessing how to expand care coordination with a different staffing mix, possibly including medical assistants. Because the program has proven so cost-effective for extremely ill patients, Larson believes it will also lower the cost of care for patients who have somewhat fewer health challenges.

    "The goal is to widen the circle of patients we can assist," she says.

    Next: A Checklist for Collaboration

    A number of themes and challenges to collaborating for results can be gleaned from this report. Go to the Last Word section of the  Leadership report.

    Or return to the full Leadership report, Collaborating for Results

    Sidebar: Person Centered

    In 2006, Catholic Health East (CHE), Philadelphia, launched a strategic planning process to define the healthcare delivery model for 2017. The end result is a coordinated, integrated care management effort that empowers individuals and communities to achieve optimal health and quality of life.

    "We tried to frame out what healthcare delivery would look like, given the impaired payment system and lack of access to care, and the closest model that we could envision over a 10-year planning horizon was person-centered care that was coordinated throughout the life cycle and across the continuum of care," says Peter DeAngelis, executive vice president and CFO.

    CHE is beginning to test comprehensive care management concepts. Pilot programs are working with managed care plans and geriatric care management programs to apply the concepts to targeted patient populations, such as Medicaid patients, geriatric patients, and the Medicare risk population.

    For more information, access HFMA's Healthcare Finance Outlook, 2009.