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Could Team-Based Care Be the Key for Care of the Chronically Ill?

By Jane Norman, CQ HealthBeat Associate Editor

August 11, 2011 -- Federal officials are searching for ways to trim the high costs of caring for people with chronic illnesses enrolled in both Medicare and Medicaid, including through the health care law. And while such new approaches as team-based care provide signs of what can work successfully, there are some pitfalls as well, health policy experts said at a briefing.

For example, disease-management programs conducted via telephone haven’t been effective, said Randy Brown, vice president and director of health research at Mathematica Policy Research in Princeton, N.J. “It’s a cheap intervention but it doesn’t work,” said Brown, adding that multiple studies have arrived at that conclusion.

What is successful is face-to-face contact between providers and patients once a month or more; small case loads for providers; strong patient education, including proper use of prescription medications; good management of departures from the hospital; and staff members with expertise in patients’ social needs, said Brown.

He and other experts participated in a briefing sponsored by the Alliance for Health Care Reform and The Commonwealth Fund, which took a look at how to improve care and manage costs for the chronically ill through the use of teams of providers.

The Department of Health and Human Services (HHS) recently announced three new programs to help streamline and improve care for dual eligibles. The Federal Coordinated Health Care Office, created by the 2010 health overhaul law ( PL 111-148 , PL 111-152 ), is charged with finding ways to save money and improve care in connection with this group.

It is a pressing question for federal entitlement programs. Cathy Schoen, senior vice president of The Commonwealth Fund, said that nine million people are so-called “dual eligibles” covered by both Medicare and the state-federal Medicaid program. While they make up just 10 percent of the programs’ total population, they accounted for 38 percent of all spending in 2007.

Schoen said that for the chronically ill, care is often complex and expensive, involving multiple sites and types of specialists. Some people may have five or more chronic conditions, with medical issues mixed together with mental illness or behaviors like smoking or obesity.

Most of the bill winds up being paid by the federal government, though insurers pay out about $68 billion through employer-sponsored private health insurance coverage.

All of it calls for more of a coordinated, multi-specialist approach to care that looks at the whole person and not just treatment of each condition, the experts said.

In Massachusetts, a non-profit health care organization that offers medical and social services to chronically ill seniors and to people with disabilities appears to have reduced hospitalizations and costs among its elderly patients.

The Commonwealth Care Alliance, which is not related to The Commonwealth Fund, focuses exclusively on the care of Medicare and Medicaid’s most costly and complex enrollees, said Linda Simon, cofounder and chief operating officer.

Primary care as organized under traditional fee-for-service Medicare is “hopelessly ineffective,” Simon said in a presentation about the program. And, she said, long-term-care services traditionally are administered without any kind of individualized care plan or coordination.

Instead, her organization uses teams of different specialists, headed up by nurse practitioners. The teams are able to order services for patients, even transportation, without prior approval from the health plan because so much less is spent on hospitalization and nursing homes, said Simon.

According to a Health Affairs article about the plan, the number of hospital days per 1,000 members in 2007 was equal to 55 percent of hospital days for comparable patients in fee-for-service Medicare.

The plan also scored at 90 percent or higher in measures for diabetes care, monitoring of patients on long-term medication and access to preventive care services.

Simon said success requires an increased investment in primary care and the “creative” provision of services and support using teams whose members are collaborators, not competitors.

Simon’s materials for the briefing cited the example of a 55-year-old woman who, when she enrolled in the program, had multiple sclerosis, a history of depression and severe asthma. She had also been a smoker. The woman, who used a wheelchair, had been in the hospital multiple times during the past two years. She did not have consistent primary care and hadn’t gotten help for her depression or smoking. She was severely depressed, withdrawn, bed-bound, suffering from pressure sores and incontinent. Her predicted expenditures were $3,800 a month.

Under the plan developed by Commonwealth, she had 72 hours a week of personal care that eventually was able to be reduced to 40 hours. She also received in-home wound care, a specialized air mattress, transportation and a smoking cessation plan. A nurse practitioner found her a primary care doctor.

A year later, the woman was far more engaged with life and her community, her ulcers were healed, she had better management of her prescriptions, her asthma had decreased though the smoking plan was only partly successful, and she had a relationship with a primary care doctor though most of her care came through the nurse practitioner. She’d had just one three-day hospitalization.

Jane Norman can be reached at [email protected].  

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