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Analysts Eye New Tactics to Deliver Chronic Care

By John Reichard, CQ HealthBeat Editor

March 23, 2009 -- Medicare demonstration programs to test better ways of treating the chronically ill don't point the way to a single best method, but other promising approaches do exist and should be pursued, panelists said at a Capitol Hill forum Monday sponsored by the seniors' lobby AARP.

Among the promising new models showcased at the forum is an approach called "guided care" in which a nurse-physician team begins with a detailed assessment of a patient's needs and a comprehensive plan of treatment. Using the resulting "care guide" and drawing on a "patient-friendly action plan" to involve the patient in managing his or her own condition, the nurse coordinates the various parties involved in care, monitors the patient and seeks to ensure that care continues as prescribed, particularly as the patient moves from the hospital to the home.

Similarly, a "transitional care" model developed by University of Pennsylvania gerontology professor Mary D. Naylor relies on planning by a registered nurse with gerontological expertise. The nurse tailors post-discharge care to each patient's situation, and provides follow-up care by phone and through home visits.

Among the lessons policy makers should draw from these approaches is the importance of following the patient through the hospital visit into other treatment settings and of in-person visits to monitor patients once they are discharged, said Susan Reinhard, director of AARP's Public Policy Institute.

Congressional aides at the forum agreed that Medicare demonstration programs offer no magic answer to the high costs and low quality that can result from the lack of coordination and monitoring characteristic of treatment of those with multiple chronic conditions.

Neera Tanden, representing the Obama administration, agreed, saying "we have limited experience with demos that are working." Tanden is a senior counselor at HHS on health overhaul issues. But Hill aides said that continued work to improve treatment could generate considerable savings and is a priority on both sides of the aisle.

Developed at the Johns Hopkins Bloomberg School of Public Health, the Guided Care Model appears to have reduced costs and boosted quality in a continuing study at eight primary care practices in the Baltimore-Washington, D.C. area.

"After the first eight months of the study, Guided Care patients experienced, on average, 24 percent fewer hospital days, 37 percent fewer skilled nursing facility days, 15 percent fewer emergency department visits and 29 percent fewer home health care episodes, as well as 9 percent more specialist visits," according to a Johns Hopkins fact sheet on the program. The summary said "these differences in utilization represent an estimated annual net savings." Patients involved rated the quality of care higher and doctors were more satisfied with communication with the patient and said they were better informed about the condition of the patient.

Use of the University of Pennsylvania transitional care model to treat congestive heart failure patients showed savings of $4,845 per patient after one year.

Mark Hayes, a GOP Senate Finance Committee health aide, said teamwork could be fostered through "accountable care organizations" that rely on a "shared-savings" model in which doctors and hospitals another providers who work together to deliver care more efficiently reap some of the financial rewards. Recently promoted at a Brookings Institution seminar by Dartmouth researcher Elliott Fisher and former Centers for Medicare and Medicaid Services Administrator Mark McClellan, the model shows promise, Hayes said.

Dan Elling, Republican staff director on the House Ways and Means Health Subcommittee, said better treatment of the chronically ill is a bipartisan priority. Elling said improved models should be designed to foster greater personal responsibility on the part of the patients, perhaps through incentives such as lower out-of-pocket premium costs for patients who manage their weight effectively.

Ashley Riddon, a legislative assistant to Sen. Blanche Lincoln, D-Ark., noted that legislation offered by her boss emphasizes a comprehensive geriatric assessment of the needs of chronically ill patents. She said that Medicare demos have shown that some design features of care do work, such as comprehensive geriatric assessments.

Mark Bayer, legislative director for Rep. Edward J. Markey, D-Mass., noted the importance of finding lower cost ways of treating people at home given the greater difficulties seniors have paying for assisted living because they can't raise enough money to enter those facilities by selling their homes in the slumping real estate market. Legislation offered by Markey and others in the last session of Congress would set up demonstration projects in 26 states to generate options to better coordinate care and keep the chronically ill in their homes and out of nursing homes as long as possible.

Chad Boult, the Johns Hopkins professor overseeing research to develop the Guided Care model, sounded a note of caution about changed payment systems, however. He said that the "shared savings" concept, for example, could in fact save money but also indicated that if not managed properly could lead to undertreatment.

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